Heritage Office Residential Delivery Screening Questionnaire

Residential Delivery Screening

The health and safety of our employees, customers, families and visitors remains the top priority of the Heritage Group. As the Coronavirus situation continues to evolve globally, we're asking you to complete this screening to help prevent the spread of or exposure to COVID-19. If you answer "yes" to any of the following questions, we respectfully request you reschedule your delivery and installation. Form must be completed prior to scheduled job. Failure to comply may result in a delay of delivery and installation.

Company Name
Point of Contact Name * Required
Point of Contact Phone Number * Required
Requested Delivery Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Delivery Location Address * Required
Delivery Location Contact Name * Required
Delivery Location Contact Number * Required
Has anyone at the delivery location 1) been diagnosed, 2) been in contact with someone who has been diagnosed or 3) been in contact with someone who may have been exposed (e.g. travelled internationally) with COVID-19 within 14 days of the scheduled delivery date? * Required
- Yes
- No
Has anyone at the delivery location experienced any cold or flu-like symptoms (including fever, cough, sore throat, respiratory illness, difficulty breathing) within 14 days of the scheduled delivery date? * Required
- Yes
- No
Will all persons at the delivery location be able to maintain physical distance from our delivery and install crew during the scheduled delivery? * Required
- Yes
- No