SCVi Covid 19 Health Screen - Senior Photos November 5 and 6, 2020
The safety of our staff, learners, and families 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 community, we are asking everyone to complete and submit this questionnaire prior to entering the 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 our employees.

MUST BE FILLED OUT ON DAY OF SENIOR PHOTO APPOINTMENT.
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Email *
First Name *
Last Name *
Phone # *
1 (a) Are you currently experiencing, or have you experienced a temperature in the past 14 days? *
1 (b) Are you currently experiencing, or have you experienced a cough in the past 14 days? *
1 (c) Are you currently experiencing, or have you experienced shortness of breath or difficulty breathing in the past 14 days? *
1 (d) Are you currently experiencing, or have you experienced sore throat in the past 14 days? *
1 (e) Are you currently experiencing, or have you experienced new loss of taste or smell in the past 14 days? *
1(g)Are you currently experiencing, or have you experienced head or muscle aches in the past 14 days? *
1(h)Are you currently experiencing, or have you experienced nausea, diarrhea, vomiting in the past 14 days? *
2. Are you currently experiencing, or have you experienced nausea, diarrhea, vomiting in the past 14 days? *
3. 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?   *
4. 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?   *
5. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?   *
6. Have you been tested for COVID-19 and are waiting to receive test results? *
7. Have you 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 of your symptoms, please contact your manager or human resources representative 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.   *
8. In the past 14 days, have you been on a commercial flight or traveled outside of the United States? *
9. 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? *
8. 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?  If “yes”, please provide a brief explanation. *
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