COVID-19 SCREENING QUESTIONNAIRE FORM

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Student ID: *

Fist Name *

Last Name *

Class *

Symptoms:

Chills *

1 point

Yes

Fatigue *

1 point

Yes

Muscle and body aches *

1 point

Yes

Headache *

1 point

Yes

Recent loss of taste or smell *

1 point

Yes

Sore throat *

1 point

Yes

Congestion and/or running nose ( if known allergy, check No) *

1 point

Yes

Nausea and/or vomiting *

1 point

Yes

Diarrhea *

1 point

Yes

Have you come into close contact (within 6 feet) with someone who has lab confirmed Covid-19 positive in the past 14 days *

1 point

Yes

* THIS FORM MUST BE COMPLETED BEFORE ENTERING THE BUILDING.

* PLEASE STAY HOME FOR 14 DAYS IF ONE OR MORE ANSWERS ARE "YES".

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