ASA COVID-19 Screening Form

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The following questions must be answered and submitted by all personnel before being permitted to enter ASA.

Email *

Have you been vaccinated for COVID -19 *

0 points

YES

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. If you have any of the following symptoms, you should NOT enter ASA but call the school at (773) 921-1315. *

0 points

Fever or felling Feverish (chills, sweating)

Difficulty breathing/shortness of breath

New cough

Sore throat/trouble swallowing

Runny nose/stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Not feeling well, extreme tiredness, sore muscles

NONE OF THE ABOVE

Required

Have you had close contact (within 6 feet for at least 15 minutes) with a person known to be infected with COVID-19 within the last 14 days? *

0 points

Yes

Have you traveled out of state to any of the restricted states recorded by City of Chicago in the last 36 hours? *

0 points

Yes

A copy of your responses will be emailed to the address you provided.

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