Health Screening Form for STUDENTS
In an effort to reduce the risk of COVID-19 exposure to Arc + Flame students and staff, all students and faculty must complete the following screening questions prior to attending class.
Name (First & Last) *
Email *
Today's Date *
MM
/
DD
/
YYYY
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms and cannot attribute them to another health condition? *
YES
NO
Fever (100.4°F or higher)
Cough
Shortness of breath
Sore throat
New loss of taste or smell
Head or muscle aches
Congestion or runny nose
Chills
Fatigue
Self-Declaration *
YES
NO
Have you visited an area where there has been a significant outbreak of COVID-19 activity in the last 14 days?
Have you been exposed to someone being tested, or who has tested positive, for COVID-19 in the last 14 days?
Are any members of your household a close contact on quarantine for exposure to COVID-19?
Have you been tested for COVID-19 and are waiting to receive test results?
Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation. *
I agree to abide by the Arc + Flame Center's rules on temperature checks, social distancing, hand-washing, and face coverings while I am visiting their facility *
Required
Certification *
Required
Submit
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