Inspired Vision Academy Elementary/Intermediate COVID-19 Visitor Self-Screening Form

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The district is concerned for your safety and the safety of staff, students, and families. We are monitoring the development of Coronavirus. In the interest of ensuring a safe and healthy learning environment, we require that you monitor your health status by carefully completing this self-assessment each day before coming to the campus.

Understanding COVID-19, and How to Stay Safe

Name *

Date *

YYYY

Campus *

Inspired Vision Academy Elementary

Inspired Vision Academy Intermediate

Are you showing any signs of the following symptoms? *

Yes

Temperature 100.0° or higher

Chills, Shaking or Exaggerated Shivering

Shortness of breath, difficulty breathing

Cough

Congestion or runny nose

Muscle or body aches

Tiredness/Fatigue

Sore Throat

Diarrhea

Headache

Nausea or Vomiting

Loss of smell, taste, or change in taste

In the past 14 days, have you been exposed to someone with COVID-19 positive test results? *

Yes

I certify that the information provided on this form is true and correct to the best of my knowledge. *

Yes

Notes

Visitation is forbidden if there has been any YES responses to the screening checklist. If “yes” is checked, visitors will be directed to leave the premises. Disinfecting the visited area will need to take place immediately.

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