Covid Waiver SLP for parents
Brooklyn Letters COVID-19 Reopening - Speech Language Therapy
Pursuant to recent orders, Brooklyn Letters is able to resume in-person speech language therapy. Please complete this form for EACH of your children who will receive in-person services by a Brooklyn Letters Speech Language Pathologist, even if that child has received in-person services at a previous time. COMPLETE A SEPARATE FORM FOR EACH CHILD RECEIVING SPEECH SERVICES. DO NOT INCLUDE MORE THAN ONE CHILD ON EACH FORM.
State your Full Name. *
What is today's date? *
State your Child's Full Name and DOB. *
What is the name of the Brooklyn Letters Speech Language Pathologist who is working with your child? *
Please read the attached Waiver and Release of Liability and verify that you have read it in its entirety and agree to its terms. *
WAIVER AND RELEASE OF LIABILITY
IN CONSIDERATION OF the risk of illness or injury from Covid 19 that exists while participating in for (hereinafter the "Service"); and
AND IN CONSIDERATION OF my choice for myself or my child/dependent to participate in said Service and being given the right to participate in same;
I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Service; and
I HEREBY release and forever discharge Brooklyn Letters SLP PLLC, located in Brooklyn Letters, New York, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releases"), from any physical or psychological injury that I may suffer as a direct result of participation in the aforementioned Service.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED SERVICE AND I AM PARTICIPATING IN THE SERVICES ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS SERVICE DUE TO COVID-19, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, TEMPORARY OR PERMANENT DISABILITY, ECONOMIC OR EMOTIONAL LOSS, AND DEATH. NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME OR THE RELEASEE, DUE TO MY PARTICIPATION IN THIS SERVICE.
Waiver and Release of Liability Page 2 of 2
I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.
I FURTHER ACKNOWLEDGE that Releases are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific service or activity on behalf of Releases.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS 'WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.
EXPRESSLY AGREE TO RELEASE AND DISCHARGE Brooklyn Letters SLP PLLC AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Brooklyn Letters SLP PLLC FOR PERSONAL INJURY OR ILLNESS.
I agree that this Release shall be governed for all purposes by New York State law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.
THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE SERVICE, DURING THIS INITIAL AND ALL SUBSEQUENT SERVICES.
Brooklyn Letters SLP PLLC
Please read the attached COVID-19 Reopening Safety Plan and verify that you have read it in its entirety and will abide by its provisions. *
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Name of Business: Brooklyn Letters SLP PLLC
Industry: Tutoring/Educational Support Services. NAICS Code 621340
Address: 1139 Prospect Avenue. #21, Brooklyn NY 11218
Name of Speech Language Feeding Therapist:
Owner/Manager of Business: Craig D. Selinger
X - Ensure 6 ft. distance between clients, unless safety or core function of the work activity requires a shorter distance.
X - Any time clients are less than 6 ft. apart from independent contractors, both must wear acceptable face coverings.
X - Tightly confined spaces will be occupied by only one individual at a time. unless all occupants are wearing face coverings.
X - While services are conducted in the home or in small spaces, and occupied by more than one person, both the independent contractor and clients will keep occupancy to only those necessary for the purpose of the services being provided.
X - Make every effort to set up work space for services being provided 6 ft. from other commonly used areas.
X - Limit in-person gatherings as much as possible and use tele- or video-conferencing whenever possible.
X - Essential in-person gatherings (e.g. meetings) should be held in open, well-ventilated spaces with appropriate social distancing among participants.
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X - Limit contact to the extent possible in the exchange of all physical items necessary for the services being provided.
List common situations that may not allow for 6 ft. of distance between individuals. In the providing of services it may be necessary for the independent contractor, clients, and/or family members to make observations or assist in implementing services in close proximity to one another in order to properly and adequately facilitate said services.
What measures will you implement to ensure the safety of your independent contractors in such situations? Educate that all services should be provided cautiously in a way that is intended to keep both the independent contractor and client safe; to wear safety masks; to wash hands when entering. exchanging physical items in the facilitation of the services, and when leaving the session: wearing gloves when appropriate.
X - Independent contractors must provide themselves with an acceptable face covering at no-cost to Brooklyn Letters SLP PLLC and have an adequate supply of coverings in case of replacement.
How will you procure these supplies? Independent contractors will be responsible for all personal procurement of such supplies.
X - Face coverings must be cleaned or replaced after use or when damaged or soiled. may not be shared, and should be properly stored or discarded.
What policy will you implement to ensure that PPE is appropriately cleaned, stored, and/or discarded? Independent contractors will provide clients and family members with their individual policies in regard to the use and care of PPE.
X - Limit the sharing of objects and discourage touching of shared surfaces; or, when in contact with shared objects or frequently touched areas, wear gloves (trade-appropriate or medical); or. sanitize or wash hands before and after contact.
List common objects that are likely to be shared between independent contractors.
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Independent contractors will determine on a case-by-case basis what common objects will be necessary for the facilitation of services.
What measures will you implement to ensure the safety of your independent contractors when using these objects? Independent contractors will provide clients and family members with their individual policies in regard to how such common items will be used/shared during the implementation of services.
X - Independent contractors will adhere to hygiene and sanitation requirements from the Centers for Disease Control and Prevention (CDC) and Department of Health (DOH) and maintain their own independent cleaning logs on their person that document date, time, and scope of cleaning of any items used in the implementation of the services.
X - Independent contractors will provide and maintain hand hygiene products for themselves and clients, including handwashing with soap, water, and paper towels, or an alcohol-based hand sanitizer containing 60% or more alcohol for areas where handwashing is not feasible.
Where on the work location will you provide independent contractors with access to the appropriate hand hygiene and/or sanitizing products and how will you promote good hand hygiene? Independent contractors will be responsible for educating their clients and families on the importance of good hand hygiene and will provide such products at each session.
X - Independent contractors will provide clients and families with a consistent means to provide updated information.
X - Independent contractors will maintain a continuous log of every person, including clients and visitors. who may have close contact with other individuals at the location of services during the timeframe of services; excluding deliveries to the location during said services that are performed with appropriate PPE or through contactless means. Said log will be kept at the individual office location(s) of the independent contractors.
X - If an independent contractor tests positive for COVID-19, the independent contractor must immediately notify Brooklyn Letters SLP PLLC, the client and client's family members (if the client is a minor), and state and local health departments and cooperate with contact tracing
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efforts, including notification of potential contacts, such as delivery personnel, critical care workers of the client, or visitors who had close contact with the individual, while maintaining confidentiality required by state and federal law and regulations.
X - At the beginning of each session, independent contractors will ask the following in regard to the client and family members of the client who live in the home: (1) COVID-19 symptoms in past 14 days, (2) positive COVID-19 test in past 14 days, and/or (3) close contact with confirmed or suspected COVID-19 case in past 14 days.
X - Independent contractors will maintain such documented reviews.
What type(s) of daily health and screening practices will you implement? Independent contractors will cancel any and all sessions if he or she feels any symptoms of illness. Independent contractors will review and follow the daily guidelines set forth by the CDC: pttos-//www.cdc,00v/coronavinis/2019-ncovklailv-life-coninalchecklist-household-readv.html
X - Independent contractors will have a plan for cleaning, disinfection, and contact tracing in the event of a positive case and report to any clients, family members, close contacts and other required authorities per CDC guidelines.
To ensure that independent contractors stay up to date on the guidance that is being issued by the State, her or she will:
X - Consult the NY Forward website at forward.ny.gov and applicable Executive Orders at govemor.ny.gov/executiveorders on a periodic basis or whenever notified of the availability of new guidance.
If you WILL NOT be able to abide by one or more of the provisions of the COVID-19 Reopening Safety Plan, please state such provisions.
Yes, I hereby consent to my typed signature below to act as an electronic signature for the Waiver and Release of Liability and COVID-19 Reopening Safety Statement included herein. *
Type Full Name as Electronic Signature *
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Document Name: Covid Waiver SLP for parents
Agree & Sign