COVID-19 Symptom Self Assessment

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This form must be completed before entering the WAC facility. For those attending classes, please complete by 8:45 AM on the morning of your class. Parents/Guardians please complete the form for your children - entering their name and reporting on their potential symptoms.

Anyone else entering the facility must complete the form before entering - this includes faculty, staff, outside contractors, visitors, etc. Thank you for your help as we work to open our doors while keeping everyone safe!

All responses will be kept confidential. When appropriate, WAC will contact the Chester County Health Department which is the acting health department for Delaware County.

First Name *

Last Name *

Best phone number to reach you *

If a student, please list the classes that you are currently attending at Wayne Art Center. If you are not a student, please state the reason for your visit. *

Have you been in contact with anyone that has been exposed to or tested positive for the virus? *

Yes

Do you feel ill?

Yes

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Please take your temperature.

What time did you take your temperature? *

Time

Was your temperature greater than 100.4 F or 38 C? *

Yes

Have you experienced any unusual feelings of tiredness? *

Yes

Have you been coughing or do you have a "dry" cough? *

Yes

Have you experienced difficulty breathing? *

Yes

While not common with the virus, have you experienced any of these other symptoms? Aches and pains, nasal congestion, runny nose, or sore throat. *

Yes

If you have a fever and/or answered "yes" to any of the above questions, please advise as to who you have been in close contact (within 6 ft for a least 10 minutes) with at the Wayne Art Center within the last 48 hours. List names of all relevant persons, and/or classes taught/attended.

If you have a fever and/or answered "yes" to any of the above questions - YOU WILL NOT BE PERMITTED TO ENTER WAYNE ART CENTER FACILITIES TODAY. You will not be permitted to return to work/teaching/class until you have been tested and cleared with a physician's note.

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