Summit Academy North - COVID-19 Health Self-Certification Form 1.21.21
To prevent the spread of COVID-19 and to reduce the potential risk of exposure, the Academy screens staff members and visitors on a daily basis at dedicated entry points. The Academy ensures that staff members and visitors utilize these entry points by barring entry via other egresses. Please answer the following questions daily as scheduled to be present in the building.
Email address *
In the past 24 hours, have you experienced any one of the following symptoms NOT explained by a known medical or physical condition: fever (above 100.4 degrees F), an uncontrollable cough, or shortness of breath? *
In the past 24 hours, have you experienced at least TWO of the following NOT explained by a known medical or physical condition: loss of taste or smell, muscle aches ("myalgia"), sore throat, severe headache, diarrhea, vomiting, abdominal pain? *
Have you tested positive in the past 14 days, or are currently awaiting the results of a COVID-19 test? *
Have you had close contact with someone that is confirmed positive for COVID-19 in the past 14 days (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting 2 days before illness onset, or for asymptomatic patients, 2 days prior to test specimen collection)? *
Please write your full name below if you attest that the above answers are true and correct to the best of your knowledge: *
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