| District of Connecticut | United States Bankruptcy Court

Are you currently experiencing, or have you experienced in the past 10 days, any of the symptoms identified by the CDC as possibly indicative of COVID-19? (i.e., cough, chills, fever of 100.4 degrees Fahrenheit or higher, shortness of breath, loss of taste and/or smell, muscle pain, sore throat.) *

Yes

Is a member of your household sick at home with COVID-19-related symptoms referenced in the first question? *

Yes

Are you, a member of your household, or a person with whom you have been in close contact with, been advised by Federal, State, or medical personnel to self-isolate? *

Yes

Have you, a member of your household, or a person with whom you have been in close contact, tested positive for COVID-19 in the past 21 days? *

Yes

If you answered NO to all of the above questions, you have self-certified in accordance with USBC's COVID-19 self-monitoring policy and may report to the workplace today.

If you answered YES to any of the above questions, DO NOT REPORT TO THE WORKPLACE. Contact your supervisor to discuss your responses and to determine whether you may report to the workplace.There are a number of workplace flexibilities in place to help you fulfill your professional responsibilities and to protect the health and safety of your colleagues and others.

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United States Bankruptcy Court

District of Connecticut

Honorable Ann M. Nevins, Chief Judge • Pietro Cicolini, Clerk of Court

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21-30817 Richard B. Kaplan, D.D.S., P.C.

20-31284

21-50521 In re Bridgeport Health Care Realty Co.

20-30263 In re Yvonne Broodie

21-20365 In re Carl Berman

19-31085 In re Jeffery French Miner

18-32011 In re Karli J. Moschetto

Lighthouse Hospitality, LLC

Health Screening Survey

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