Westampton Adult Ed One Time COVID Screening Form

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Adult Education Student,

This form is required to be completed one time and subsequently reviewed daily by you prior to attending class and/or clinical.

Thank you,

Mr. Pappler

Student Name (First and Last) *

Campus - Westampton *

Westampton

Required

Any of the symptoms below could indicate a COVID-19 Infection and may put you at risk for spreading illness to others. Please note that this list does not include all possible symptoms and individuals with COVID-19 may experience any, all, or none of these symptoms. Please check yourself daily for these symptoms.

Section A - If TWO OR MORE of the symptoms in this section are checked off, you must stay home and notify Adult Ed Administration for further instruction. *

Fever (Measured or subjective)

Chills

Rigors (Shivers)

Myalgia (Muscle Aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or Runny Nose

NONE OF THE ABOVE

Required

Section B -If AT LEAST ONE symptom in this section is checked off, you must stay home and notify Adult Ed Administration for further instruction. *

Cough

Shortness of Breath

Difficulty Breathing

New loss of smell

New loss of taste

NONE OF THE ABOVE

Required

Program - Please select from the drop down list *

Close Contact/Potential Exposure

If ANY of the fields in the 'Close Contact/Potential Exposure' section are checked off, you should remain home for 14 days from the last date of exposure (if you are a close contact of a confirmed COVID-19 case) or date of return to New Jersey.

Contact your provider or your local health department for further guidance.

Close Contact/Potential Exposure (Please verify if:)

You had close contact (within 6 feet of an infected person for at least 15 minutes or more over a 24 hour period) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

You traveled to an area of high community transmission. https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey

Complete this section only if you work in a HEATHCARE Facility

I work in a healthcare facility and I am tested for COVID-19 on a weekly basis. I will advise BCIT Adult Education administration immediately if I experience any symptoms of COVID-19, which are identified in this document, and/or if there is a change to my health status at any time, including, but not limited to the time in between my COVID-19 Tests.

Select "Yes" in the dropdown to verify that all information on this form is correct to the best of your knowledge and to sign off on the understanding that you have the responsibility to check symptoms daily prior to coming to class and/or clinical. You also agree to notify the Adult Education administration if symptoms preclude you from attending class and/or clinical. *

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