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 5 is “No” that person will not be permitted to attend the in-person showing or meeting; (vi) any person may be asked in the future to execute another Form in connection with a future meeting and/or showing; and (vii) 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.

SCREENING QUESTIONS

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?

2. Have you tested positive for COVID-19 in the past 14 days?

3. Have you experienced any symptoms of COVID-19 in the past 14 days?

4. In the last 14 days, have you traveled from another state or country for which New York State requires a mandated self-quarantine period?

5. If you answered “Yes” to question 4, have you completed the 14 day self-quarantine as currently required by New York State?

Name:

Email:

Date:

Signature:

Property Address:

Name of Real Estate Licensee:

Name of Brokerage Company:


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.

Real Estate Board of New York | rebny.com

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