Return to Community Questionnaire
Please fill out this questionnaire regarding MARC, Inc.'s reopening of day programs and work sites.
Your Name
*
First Name
Last Name
Phone
*
(xxx) xxx-xxxx
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Name of person returning to MARC, Inc.
*
First Name
Last Name
Department
*
DSO/ With Work
Employment
Senior Center
Shannon's Place
Does the person have any risk factors identified by the CDC that puts that person at a higher risk level?
*
Yes
No
Can the person protect themselves and others by washing their hands often; avoid touching their eyes, nose and mouth; cover their coughs and sneezes and wear protective mask or cloth face covering?
*
Yes
No
Are you willing to allow staff to transport the person in a vehicle (with a max number of 4 people)?
*
Yes
No
Are you willing and able to provide transportation to and from work/day program daily?
*
Yes
No
Are you willing to allow the person to ride ADA if that is their normal means of transportation?
*
Yes
No
N/A
Please list any additional questions or concerns you may have for having the person return to the day program or work site.
Will the person be able to return to their day program or work site when MARC, Inc. reopens?
*
Yes
No
I give permission for the person named above to return to work.
*
Yes
No
Please sign in the box below.
*
Submit
Should be Empty: