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Plato Learning Academy COVID-19 Screener
All employees, students, parents, and visitors to the school must complete this form before they are can enter the building.
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General Information
Name
*
Your answer
Role
*
Employee
Student
Parent
Vendor
Visitor
Other:
Purpose of Visit
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Screener Questions
In the last 24 hours have you experienced any of the following symptoms that you cannot attribute to another health condition? Please check all that apply. If yes to any, you must leave the building immediately and contact your physician.
*
Fever greater than 100.4* F or chills
Cough
Shortness of breath / difficulty breathing
Fatigue
Muscle of body aches
Headache
New loss of taste of smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarhhea
None of the above
Required
Have you been in close contact with a person who has tested positive for COVID-19 in the past 14 days? If yes, you must leave immediately and quarantine for 14 days.
*
Yes
No
Have you traveled outside of the state in the past 14 days?
*
Yes
No
If so, what state(s) did you visit?
Your answer
Have you traveled internationally in the past 14 days?
*
Yes
No
If so, what country did you visit?
Your answer
Have you tested positive for COVID-19 in the past 10 days? If yes, you must leave immediately to complete at least 10 days from your first symptom AND 24 hours since your last fever without the use of fever-reducing medications AND your other symptoms are improving
*
Yes
No
Are you waiting on the results of a COVID-19 test? If yes, you must leave immediately to wait on your test results.
*
Yes
No
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