LWA5 - COVID-19 Screening Survey
This LoveWorks Academy for Arts form must be completed by all employees, visitors, contractors and vendors daily to enter the building. Middle school students will be trained gradually to complete this form as well.  If you have ANY symptoms, please contact our front office at (763) 522-6830 and ask for the COVID Coordinator.  We BELIEVE in Better!
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Email *
Please indicate which group(s) you are part of. Check all that apply. *
Do you have or are you experiencing any of the following? Check all that apply. *
To the best of your knowledge, during the past 14 days, have you been within 6 feet of a person with a lab confirmed case of COVID-19 for a total of 15 minutes over a 24 hour period, had direct contact with that person's mucus or saliva, or been contacted by public health and told you were in close contact with someone known to have COVID-19? Do you live with anyone that has had a confirmed case of COVID-19 in the past 24 days? *
First Name *
Last Name *
Date of Completion *
Time of Completion *
A copy of your responses will be emailed to the address you provided.
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