Health Screening Questionnaire
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The safety of our students 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 & Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our students and staff, we are asking everyone to complete and submit this questionnaire prior to attending Chartwell sponsored events.
Student Name *
Are you experiencing the following symptoms? *
Yes
No
Cough
Shortness of breath
Difficulty breathing
Fever
Chills
Muscle pain
Sore Throat
New loss of taste or smell
Have you been in contact with someone known or presumed to have COVID-19 within the past 14 days? *
Required
Temperature: *
Temperature 100˚and over MUST stay home.
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
Parent / Legal Guardian Name *
Date *
MM
/
DD
/
YYYY
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