Naumann Visitor Health Self-Screening
Please complete this form before entering the building.

All visitors must minimize in-person contact by maintaining 6 feet of separation from other individuals, not from the same household, and always wear appropriate face covering or mask.

All visitors must be able to check no to any of the following that is new or worsening signs of symptoms of possible COVID-19 before entering building:
Have you recently had any contact with anyone that is/has tested positive for COVID-19? *
Required
Do you have a new or worsening cough or shortening of breath/difficulty breathing? *
Required
Do you currently have a fever or have had one in the past 72 hours? (greater than or equal to 100 degrees Fahrenheit) *
Required
Indicate "Yes" if you are experiencing any of these symptoms that are not normal for you or check "No" if you are NOT experiencing the following symptoms. -Loss of taste or smell; Cough; Difficulty Breathing; Shortness of breath; Fatigue; Headache; Chills; Sore throat; Congestion or runny nose; Shaking or exaggerated shivering; Significant muscle pain or ache; Diarrhea; Nausea or vomiting If you answer "yes," you cannot enter the school building. *
Required
Who is your appointment with here at Naumann? *
What time is your appointment? *
Signature (first and last name) *
Date Signed *
MM
/
DD
/
YYYY
Phone Number where you can be reached *
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