Covid-19 Screening Questionnaire

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Any individual who is found to have a temperature of 100.4 or above, or who answers yes to any of the following or similar questions, shall be denied entrance to the facility.

First And Last Name (If your a parent please fill in both yours and your child's name) *

Are you experiencing TWO OR MORE of the following symptoms?Fever (measured or subjective)Chills(shivers), Myalgia (muscle aches),Headache,Sore Throat, Nausea or Vomiting, Diarrhea, Fatigue, Congestion, or runny nose *

Yes

Are you experiencing ANY of the following symptoms? Cough,Shortness of Breath, Difficulty Breathing, New Loss of Smell, New Loss of Taste *

Yes

In the past two weeks have you been in contact with someone diagnosed with COVID-19? *

Yes

Have you traveled outside of NJ in the last 14 days to a state on the quarantine list? Quarantine List: 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 *

Yes

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