Health Questionnaire Screening Form

Health Questionnaire Screening Form for Coronavirus (COVID-19)

The Real Estate Board of New York (REBNY) has put together this Coronavirus (COVID-19) Health Screening Questionnaire Form (the "Form") which shall be distributed to all persons who are attending any in-person property showings and/or meetings with the undersigned real estate licensee (the "Broker"). This Form shall be distributed to all attendees within 24 hours of any scheduled meeting. Please understand that the purpose of this Form is to elicit information to help promote the health and safety of all persons who may be involved in the meeting and/or showing, and that taking precautionary measures to prevent the spread of the Coronavirus (COVID-19) is paramount to those efforts.

The Broker (or any agent of the Broker) may cancel or postpone any in-person showing or meeting without prejudice or penalty upon any indication that a person who is attending the showing or meeting is exhibiting any symptoms of the Coronavirus (COVID-19) or any other cold or flu-like symptoms.

The person signing this Form hereby acknowledges and agrees that: (i) the information requested on this Form is being provided voluntarily, (ii) the information provided on this Form is confidential and is not intended for use outside of determining whether an in-person showing or meeting can occur, (iii) the refusal or failure to answer each question below may result in the cancellation of any scheduled meeting or showing, and that the Broker reserves the absolute right, in their sole discretion, to refuse entry to that person; (iv) if the answer to questions 1-3 is “Yes” that person will not be permitted to attend the in-person showing or meeting; (v) if the answer to question 4 is “Yes” and the answer to question 4a is “No” that person will not be permitted to attend the in-person showing or meeting; (vi) if the answer to question 5 is “Yes” and the answer to question 5a is “No” that person will not be permitted to attend the in-person showing or meeting; (vii) any person may be asked in the future to execute another Form in connection with a future meeting and/or showing; and (viii) they must notify the real estate licensee listed below if they become symptomatic and/or test positive for COVID-19 within 48 hours of the last visit to the property. The Broker represents that they use and present this Form uniformly and in the same manner for all in-person interactions and meetings and in accordance with all Federal, State and Local Fair Housing Laws.


Please answer the following 5 questions:

  1. Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19?
    YES NO
  2. Have you tested positive for COVID-19 in the past 14 days?
    YES NO
  3. Have you experienced any symptoms of COVID-19 in the past 14 days?
    YES NO
  4. In the past 10 days, have you traveled more than 24 hours to a state or country for which New York State requires a quarantine?
    YES NO
    1. If yes, have you quarantined for at least three (3) days, been tested for COVID-19 on or after the fourth (4th) day of returning to New York and received a negative test result? OR have you quarantined for 10 days?
      YES NO
  1. In the past 10 days, have you traveled less than 24 hours to a state or country which New York State deems to have a significant degree of community-wide spread of COVID-19?
    YES NO
    1. If yes, did you take a COVID-19 test on or after the 4th day following your arrival and receive a negative test result?
      YES NO

*Per updated CDC guidance released on February 10, 2021, “asymptomatic fully vaccinated individuals,” meaning those who have received both shots, are no longer required to quarantine if they have been in close contact with a person who has COVID-19. However, at least two weeks but no more than 90 days must have passed since the individual’s second shot prior to the exposure. Please read more from New York State here and the CDC here.

Please also note that PPE, social distancing and other protective protocols are still required and enforced for ALL individuals, including those fully vaccinated.


Important Note: This Form should not be construed as offering or providing legal advice in any form. This Form is not intended to replace the reader’s need to speak with their own legal counsel regarding the issues presented. All readers should seek independent legal advice prior to instituting any re-entry policies and/or practices.

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Oxford Property Group. You are also confirming that you are the party authorized to enter into this Agreement. You further agree that each use of your E-Signature and constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form.