IAH COVID-19 Questionnaire

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This is an Amanah that you answer these questions honestly to the best of your knowledge. This is for the protection for our students, families, and staff. Remember, if you falsely answer these you are putting everyone's health at risk.

Before anyone is allowed to enter IAH facility, including students, parents or guardians, visitors, etc., will be subject to temperature checks and required to answer the following COVID-19 screening questions:

Name *

Today's Date *

YYYY

Grade/Title *

Preschool

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

Staff

Parent/Guardian

Visitor

Have you experienced any of the following symptoms in the past 48 hours (check all that apply): *

fever or chills (temperature over 100.4° F or 38° C)

cough

shortness of breath or difficulty breathing

fatigue

muscle or body aches

headache

new loss of taste or smell

sore throat

congestion or runny nose

nausea or vomiting

diarrhea

none of the above

Required

Have you taken any fever-reducing medications within 24 hours (i.e. Tylenol, Ibuprofen, etc.)? *

Yes

I do not know.

Have you, or anyone you have been in close contact with, been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last two weeks (14 days)? *

Yes

Have you been asked to self-isolate or quarantine by a medical professional or a local public health official in the last two weeks (14 days)? *

Yes

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