Effective 6/23/2020 for DOE 20/DHS 19
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If the questions from Page 1 are all answered NO by the client, then the following questions
need to be asked to insure the safety of both WAP staff and clients:
1. Will you be willing to vacate the WAP work area during WAP work (another room with a
door or plastic wall, or outside), AND, only the homeowner/client can be present (this
cannot be a minor)? (Take into consideration some families cannot find childcare)
2. Will you be willing to wear a face covering (while in the same room/area as WAP staff)
during the WAP work?
3. Will you be willing to sign a COVID-19 Hold Harmless Agreement? See Page 4.
Based on the answers provided by the client, the WAP staff member conducting the interview
must make a decision whether WAP work can proceed or the home needs to be deferred.
If any of the questions from page one are unanswered or uncertain, it is up to the WAP staff
member conducting the interview to make a decision about deferral. If the questions cannot be
answered, and the risk of exposure cannot be determined, the home may need to be deferred
for 30 days.
Provide the client with any educational resources during this time and upon first arrival to the
home. Educate the client on what safety practices we are implementing and any other
pandemic related education.
Any remarks, clarification, or documentation provided by the WAP staff member, needs to be
added to this document on the last page. Any additional client check-ins are documented here.
Keep a copy of this questionnaire in the client file and provide a copy to the client upon
completion of the home.
This questionnaire was conducted on the following date: ________________________, 2020
WAP Staff Name
WAP Staff Signature
