Aidan Montessori School Event Attendee Questionnaire (New Family Breakfast

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Aidan Montessori School Event Attendee Questionnaire (New Family Breakfast - 10/13)

Please provide us with this information before attending any in-person events. Please complete one form per attendee. As a reminder, we require that all New Family Breakfast attendees show proof of vaccination in order to attend the event. Proof of vaccination may be emailed directly to Nurse Lexi (l.pollack@aidanschool.org) or shown at arrival to the event.

We are required to keep this information on file for 30 days for the DC Department of Health in case there is a breakout of COVID-19 at an event.

Full Name *

Phone Number *

Email *

Event Date (10/13/21) *

YYYY

In the last 72 hours, have you experienced any of the following symptoms that are new or unexplained: *

Fever of 100.4℉ or higher, chills

Shortness of breath, difficulty breathing, new loss of taste or smell

Nausea, vomiting, diarrhea

An uncontrolled cough, severe headache

Muscle/body aches, fatigue

Sore throat, congestion, runny nose

None of the above

Required

In the last 10 days, have you traveled outside the DMV and not followed the appropriate measures after your return? (Unvaccinated: tested 3-5 days after return and quarantine while awaiting results; Vaccinated: tested 3-5 days after return from international travel without quarantine) *

Yes

In the last 14 days, have any of the attending family members been in close contact (within 6 feet or less, for more than 15 minutes, over a 24 hour timeframe) with a person who has tested positive for COVID-19? *

Yes

Is anyone in your family currently awaiting the results of a COVID-19 test? *

Yes

Has anyone in your family tested positive for COVID-19 in the past 14 days? *

Yes

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