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 individuals (students, faculty, staff, and pre-approved visitors) to complete the following health screening questionnaire before entering our school buildings each day. Please complete and submit the questionnaire on the day of your scheduled visit at least one hour before arrival. If you answer 'YES' to any of questions 1 through 5, please stay home.
Name of the person who is completing this health screening (ie. on behalf of oneself or on behalf of one's student): *
Email address: *
Name of the person for whom this health screening is being completed (hereinafter "you"): *
Role of the person for whom this health screening is being completed: *
Grade level if this screening is being completed for a student (otherwise, choose N/A): *
1. Have you experienced any symptoms of COVID-19 in the past 14 days, including: (a) a temperature of greater than 100.0°F, (b) sore throat, (c) NEW uncontrolled cough that causes difficulty breathing (for individuals with chronic allergic/asthmatic cough, a change in your cough from baseline), (d) diarrhea, vomiting, or abdominal pain, or (e) NEW onset of severe headache, especially with fever. If you are an adult, have you experienced any of the following adult-specific symptoms in the last 14 days: (a) NEW loss of taste or smell, (b) unexplained chills, fatigue, or muscle/body aches, or (c) unexplained runny nose? *
2. Have you had a positive COVID-19 test in the past 14 days? *
3. Have you been mandated or advised by a government agency or healthcare provider to isolate or self-quarantine due to personal illness, illness of an individual you have had close contact with in the past 14 days, or due to travel to or from a hot spot, in the past 14 days? *
4. Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19? *
5. Have you traveled to or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days? *
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