Nanny COVID Level Form

Email: *

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Please describe any other details you wish to share or precautions you are taking: *

Do you or your household members work remotely at home, or leave for work?

Do you have any household members who work in high-risk situations?

Yes

No

Phone Number: *

Have you received the COVID vaccine?

Yes

No

Do you have any close family members you are socially distancing for? *

Name: *

Would you be willing to adjust your precautions to align with the family's?

Yes

No

Of the three levels, which most accurately reflects your current level of precautions?

Level 1

Level 2

Level 3

Are you socially distancing?

Yes

No

Have you received just Dose one? or both doses?

Both

Just dose one

Are you willing to limit your exposure with friends and others?

Yes

No

How many people are in your household?

0-1

1-2

2-3

4+

Do you wear a mask in public?

Yes

No

Above & Beyond Nanny Services, Inc.