Rudolf Steiner School - COVID-19 Health Screening Questionnaire
Rudolf Steiner School (the "School") values each member of our community and prioritizes keeping everyone safe. As part of these efforts, we require all pre-approved visitors (including parents) to complete the following health screening questionnaire before entering either of our school buildings. Please complete and submit the questionnaire on the day of your scheduled visit at least one hour before arrival.

**If you respond YES to any of the questions below, please stay home and contact our Health Office Team at nurse@steiner.edu.**
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Name of the person who is completing this health screening (ie. on behalf of oneself or on behalf of one's child): *
Email address: *
Name of the person for whom this health screening is being completed (hereinafter "you"): *
Reason for visit: *
1. In the past 14 days, have you experienced any symptoms of COVID-19, including: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *
2. In the past 10 days, have you had a positive COVID-19 test result or have you been mandated or advised by a government agency or healthcare provider to isolate or self-quarantine? *
3. In the past 14 days, to your knowledge, have you been in contact with anyone who has tested positive for COVID-19? *
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