20-21 Coronavirus 2019 (COVID-19) Health Screening Questionnaire

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As part of our efforts to keep all employees, visitors, and patrons safe, we ask that you please complete the following health screening questionnaire prior to entering the premises.

PLEASE FILL OUT THIS FORM BEFORE YOU COME TO SCHOOL

Example: If you are coming to school at 8AM, please fill this out at 6:30AM. Thank you.

Last Name *

First Name *

Date: *

YYYY

Time: *

Time

Purpose of visit: *

Have you been come into close contact with someone who has a suspected or laboratory confirmed COVID-19 diagnosis in the last 14 days? *

Yes

Have you tested POSITIVE or have pending test results for COVID-19 within the last 14 days? *

Yes

Have you felt like you had a fever or chills within the last 14 days? *

Yes

Do you have a new or worsening cough within the last 14 days? *

Yes

Shortness of breath or difficulty breathing that is not due to another health condition? *

Yes

Weakness / Fatigue (tired) within the last 14 days? *

Yes

Muscle or body aches that is not due to another health condition? *

Yes

Headache within the last 14 days? *

Yes

Unable to taste and/or smell? *

Yes

Sore or scratchy throat within the last 14 days? *

Yes

Congestion or runny nose? *

Yes

Nausea, vomiting or diarrhea within the last 14 day? *

Yes

If an individual answers “YES” to any of the screening questions, the individual should not visit or report to the building and report the symptoms to the building administrator. The individual should isolate immediately, be asked to wear a facemask/cloth covering and be advised to leave and to contact their healthcare provider for further evaluation.

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