COVID-19 Visitor Wellness Attestation

To ensure the safety of our employees and visitors, Sterne, Kessler, Goldstein & Fox is requiring all outside visitors to complete this Wellness Attestation prior to entering the office. This requirement is in accordance with local and federal rules and guidance related to the current pandemic. After reviewing this form, Sterne Kessler may require additional information or further follow up action.

* required information

Full Name

Company

Confirm Email

Phone

In the last 14 days, have you experienced any of the following?

Temperature above 99.6°F

Close contact with anyone who has exhibited COVID-19 symptoms, who has been instructed by a healthcare provider to self-quarantine within the past 14 days, or who has been diagnosed with COVID-19

Cough

Shortness of breath or difficulty breathing

New loss of taste or smell

Cold symptoms such as sore throat, runny nose or congestion

Nausea, vomiting or diarrhea

None of the above

In the last 14 days, have you taken a COVID test?

Yes - Positive Results

Yes - Negative Results

Yes - Awaiting Results

Upon entering Sterne Kessler's office, I agree to abide with the following requirements:

I will wear a mask at all times while in Sterne Kessler's office.

I will limit my movement while in the office to only the necessary and allowed spaces and the nearest restroom.

I will notify the meeting host and leave the firm's office immediately if I begin to develop any COVID-19 symptoms.

I will notify the firm if diagnosed with COVID-19 within the 14 days after visiting Sterne Kessler's office.