Cleaning Services Health Declaration Form
Cleaning Services Health Declaration Form
To further safeguard everyone involved, we require our client to complete this form before availing of our cleaning services. Your cooperation in providing accurate information is essential in maintaining a safe environment for everyone.
Personal Information
Name
Date of Birth
Address
Phone number
Health Declaration
Please answer the following questions honestly:
Have you or anyone in your household experienced any illness or symptoms in the past 14 days that may be contagious?
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Yes
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No
Have you or anyone in your household been diagnosed with any contagious illness or condition in the past 14 days?
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Yes
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No
Have you or anyone in your household been in close contact with someone who has a contagious illness or condition in the past 14 days?
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Yes
-
No
Have you or anyone in your household traveled internationally in the past 14 days?
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Yes
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No
Do you currently have any health conditions or concerns that may affect your ability to safely participate in cleaning activities?
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Yes
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No
Are you allergic to any cleaning products or materials commonly used in cleaning services?
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Yes
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No
Do you have any physical limitations or disabilities that may require accommodation during cleaning services?
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Yes
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No
Declaration
I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that providing false information may put others at risk and may result in the cancellation of cleaning services.
Name:
Date:
