Oakwynne Maintenance Request Form

FULL NAME *

First Name Last Name

PHONE NUMBER *

ex: 555-555-4256

E-MAIL *

ex: myname@example.com

APARTMENT NUMBER *

PETS RESIDE IN YOUR APARTMENT? *

OAKWYNNE HOUSE HAS PERMISSION TO ENTER YOUR APARTMENT? *

Yes No

MAINTENANCE REQUEST *

Please add as much detail as possible.

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Does anyone in your household have any one of these symptoms: fever or chills, cough, shortness of breath/trouble breathing, fatigue, diarrhea, muscle or body aches, headache, nausea or vomiting, new loss of taste or smell, sore throat, congestion or runny nose? *

Yes No

IN THE LAST 14 DAYS, HAS ANYONE IN THE HOME/SUITE TRAVELED OUTSIDE THE UNITED STATES? *

Yes No

Has anyone in your household had any of the previous symptoms in the last 72 hours? *

Yes No

Do you or a member of your household currently have COVID-19 or have a pending COVID-19 test? *

Yes No

Do you or a member of your household have a pending COVID-19 test? *

Yes No

Do you or a member of your household currently have COVID-19? *

Yes No

Have you or a member of your household been in contact with someone suspected or confirmed to have COVID-19 within the last 10 days? *

Yes No

Is anyone in your household considered an essential or life sustaining worker? *

Yes No

In the past 14 days, has anyone in your household traveled out of state? *

Yes No

In the past 14 days, has anyone in your household been quarantined or self-quarantined by a health care professional? *

Yes No

In the past 14 days, has anyone in your household been quarantined? *

Yes No

Have all members of your household been following the governor’s ‘stay at home’ order? *

Yes No

Have all members of your household been practicing social distancing and mask wearing outside of your household? *

Yes No

Our maintenance team member will wear a face mask in your home if you prefer. Please indicate whether you prefer they wear a mask. At any time, during the visit please feel free to request they wear a mask. *

Yes No

Please verify that you are human *

If this is a Maintenance EMERGENCY and the office is closed please call the Emergency Maintenance phone number at 610-642-5253. All calls will be addressed during Oakwynne House Office Hours which are Monday-Friday: 9:00AM-6:00PM.