Ferocity Dance Company Student / Visitor Health Screening Questionnaire
In order to prevent the spread of the coronavirus and reduce the potential risk of COVID-19 exposure to our dancers, we are asking everyone to complete and submit this questionnaire prior to entering the studio. This must be filled out every time you will be entering our office or studio to participate in an activity or meeting of any sort - do NOT fill this out earlier than the day you're coming to our studio. Please do not enter the studio until your responses have been reviewed and your entry has been approved.
PLEASE NOTE: As is stated on our website, dishonesty in this questionnaire will result in a permanent ban from the studio.
* Required
Email address
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Your email
Today's Date
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Full Name:
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Your answer
Date of Birth
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Contact Phone Number
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Your answer
In the past 48 hours have you had any of the following?
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Fever or Chills
Cough
Shortness of Breath or Difficulty Breathing
Fatigue
Muscle or Body Aches
Headache
New loss of taste or smell
Sore throat
Congestion or Runny nose
Nausea or Vomiting
Diarrhea
I have had no symptoms of any kind
Required
Are you ill, or caring for someone who is ill?
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Yes, I am ill
Yes, I am caring for someone who is ill
I work in healthcare and am a Doctor or a Nurse taking care of COVID patients
No
Have you been at a social gathering within the last two weeks? Gathering can be anything involving 3 or more people including you.
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Yes, with people I have and have not quarantined with but we wore masks whenever not actively eating or drinking.
Yes, with people I have and have not quarantined with and we did not always wear masks even when not actively drinking or eating.
Yes, with people I have quarantined with only.
No
Have you smoked hookah in a social setting within the last two weeks?
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Yes
No
Have you social danced within the last two weeks?
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Yes
No
Have you been in close contact with anyone who has exhibited any symptoms within the last two weeks?
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Yes
No
Have you been in contact with anyone who has tested positive for COVID-19 within the last two weeks?
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Yes
No
Have you been tested for COVID-19 within the last two weeks?
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Yes, I tested negative
Yes, I tested positive
Yes, I'm waiting for my results
No
In the past 14 days, have you traveled outside of the state of VA?
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Yes
Yes but keeping within the DMV Metro area or within 60 miles from the studio
No, and I stayed within 60 miles of the studio
No, but I traveled a distance farther than 60 miles from the studio
In the past 14 days, have you been on a commercial flight or had contact with someone who has?
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Yes
No
In the past 14 days, have you traveled outside of the United States or been in contact with someone who has?
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Yes
No
Do you hereby certify that the responses provided above are true and accurate to the best of your knowledge?
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Yes
A copy of your responses will be emailed to the address you provided.
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