WHARTON INSTITUTE FOR THE PERFORMING ARTS COVID-19 SCREENING QUESTIONNAIRE
The safety of our students, faculty and other staff members is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering our site. Please do not enter the site until your responses have been reviewed and your entry has been approved.
 
Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and your fellow students, faculty and other staff members.
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Name *
Phone # *
What time is your lesson? If you are a parent/guardian, please answer with student's lesson time. *
WAIVER
In consideration of my [and/or my child's or children's] participation in this course or program, I hereby fully release and discharge the Wharton Institute for the Performing Arts, and its representatives, successors, and assigns, from any and all liability arising from accident, injury, and/or illness, including but not limited to any form of pandemic like COVID-19, that I (he/she) may suffer as a result of my (our) participation in this course or program. I (we) also will follow the rules and regulations set by the Wharton Institute for the Performing Arts and above named parties. Parent or guardian must sign for anyone under the age of 18.I do hereby grant and give these groups the right to use my or my child(s) photograph or image without my or my child's name, both singly and in conjunction with other persons or objects and presentations, advertising, publicity, and promotion relating thereto. For Performing Arts School students, I have read and agree to the Policies and Procedures (PAS Policies and Procedures) on the Wharton website. New Jersey Youth Symphony and Paterson Music Project programs may have additional requirements and procedures. Please refer specifically to those programs for further information.
Have you read and understood the Wharton Institute for the Performing Arts Waiver above? *
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?(Please take your temperature before you answer this question.)  
Cough *
Shortness of breath/difficulty breathing *
Sore Throat *
New loss of taste, smell *
Chills *
Head or muscle aches *
Nausea, diarrhea, vomiting *
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
Have you been tested for COVID-19 and are waiting to receive test results? *
Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? (NOTE: If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms, please contact us when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medications; (2) your other symptoms have improved; and at least 7 days have elapsed since your symptoms first appeared. ) *
In the past 14 days, have you been on a commercial flight or traveled outside of the United States? *
In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States? *
Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? Please type yes, or no. If “yes”, please provide a brief explanation. *
Kindly take your temperature at home before arriving for your session, and record your temperature below: *
Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to your manager or your human resources representative. *
Confirmation Signature, in print *
Today's Date *
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