Pacem School COVID-19 Health Screening

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Community Member Name *

Do you have any of the following symptoms: *

Cough

Shortness of breath

Chills

Fatigue

Muscle Pain or body aches

Headache

Sore throat

Loss of taste or smell

Congestion or runny nose not associated with diagnosed allergy

Nausea, vomitting, or diarrhea

NO SYMPTOMS

Required

Student has above symptoms, but is OK'd by a health-care professional. Explain:

Have you been to any gatherings involving unvaccinated people from more than 2 households in the last 14 days? *

Yes

Have you been exposed to anyone with COVID-19? (defined as close contact with a person who has COVID-19 within the last 14 days. A close contact is someone who was within 6 feet of an infected person for at least 15 minutes starting from 48 hours before illness onset until the time the patient is isolated.) *

Yes

Have you traveled out of state in the last 7 days without being vaccinated or waiting 3 days upon return and being tested? *

Yes

If so, where?

What is the person's current temperature? *

below 98

98-99

99-100

100-100.3

100.4 or above

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