Omega Alpha Academy: COVID-19 Survey

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Email *

Student Name and Grade Level *

Have you experienced any of the following symptoms in the past 48 hours? *

Fever or Chills

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

Required

Have you been in close physical contact in the last 14 days with: *

Anyone who is known to have laboratory-confirmed COVID-19?

Anyone who has any symptoms consistent with COVID-19?

Yes

Maybe

Are you currently waiting on the results of a COVID-19 test? *

Yes

Maybe

Have you traveled in the past 10 days? *

Yes

Maybe

If you are 12 years and older, are you fully vaccinated? *

Yes

Would you be interested in having COVID testing on school campus? *

Yes

Maybe

Parent Contact Information (Name, Phone Number, and Email Address) *

A copy of your responses will be emailed to the address you provided.

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