USN COVID-19 Health Screening
Students, parents, vendors, and other campus visitors are required to complete this form daily before entering USN buildings.
First Name *
Last Name *
What is your relationship to University School of Nashville? *
Those who answer “yes” to any of the following questions may not enter USN buildings. *
*Close contact is defined as being within approximately 6 feet of a person with confirmed COVID-19 for a prolonged period of time -OR- having direct contact with infections secretions of a person with COVID-19
Yes
No
Within the last 14 days, have you had or do you currently have a new onset of cough or shortness of breath?
Within the last 14 days, have you had or do currently have a body temperature of more than 100.4 degrees Fahrenheit?
Within the last 14 days, have you had or do you currently have chills, loss of taste and smell, or any other symptoms known as consistent with COVID-19?
Within the last 14 days, have you or anyone you have been in close contact* with had a positive test for COVID-19?
Within the last 14 days, have you or anyone you have been in close contact* with been put in mandated quarantine for COVID-19?
Are you or anyone you have been in close contact* with awaiting test results for COVID-19?
Electronic Signature *
As indicated by my initials/signature below, I certify that I have read, understand, and agree with all of the information provided in this questionnaire and my responses to all questions are TRUE AND ACCURATE. Further, I understand that any false or misleading responses could result in disciplinary action and/or immediate removal from campus.
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