IMPERIUM ENTERTAINMENT BUREAU

HEALTH SCREENING FORM & COVID-19 QUESTIONNAIRE

The I.E.B.’s health screening form’s purpose is to accommodate or show support to talent or crew
members in order to provide proper help regarding health needs.

All answers regarding personal health provided will be kept private and will not be forwarded to anyone
outside of the platform:

SCREEN QUESTIONS

1. Do you have any serious medical conditions that might interfere with filming? If so,
please list:

2. Do you have any allergic reactions to any pets, foods, or any other materials? If so, please
list so:

3. Do you have any mental or emotional condition(s) that can affect work? If so, please list:

4. Do you have any physical disabilities that may interfere with filming?
5. Any current diet rules/changes pertaining to any religious affiliations such as: Fasting,
etc? Any diet restrictions? Ex: Vegan, Vegetarian, Liquid diet, Soft food diet, etc:

6. Any special medications you take that may interact negatively with certain foods or
drinks? If so please list so:

7. Are you under the age of 18? If so, please bring a legal guardian to set. (Anyone under the
age of 18 is required to do so.)

8. 8. For the sake of COVID safety please evaluate and fill out the
Covid-19 Questionnaire below.
 COVID-19 QUESTIONNAIRE

1. Do you currently have or have experienced the following symptoms within 24 hours:
Fever, shortness of breath/difficulty breathing, chills, cough, muscle pain, sore throat,
loss of taste or smell, dizziness?

2. Have you been exposed or come into contact with anyone positive with Covid-19 the last 14
days?

3. Have you recently traveled out of country (U.S.) within the last 14 days?

4. Have you been vaccinated receiving both shots of Pfizer, Moderna, or Johnsons & Johnsons
vaccines?

5. Have you received a booster shot? (Booster shots are not required).
6. If recently tested, was the result positive or negative?