CSD's Staff COVID-19 Screening Form
EACH STAFF MEMBER MUST FILL OUT A FORM EACH TIME THEY ENTER THE STUDIO
First Name *
Last Name *
Phone Number *
Date *
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To prevent the spread of COVID-19 and to help protect each other, I understand that I will have to follow CSD's strict guidelines. *
Have you had any of the following symptoms in the past 3 days? Cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, headache, nausea, vomiting, diarrhea, runny nose or stuffy nose, fatigue, and/or recent loss of taste or smell? *
Have you been in contact (less than 6 ft away) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days? *
Has you traveled to another state, for non work related purposes that currently has a stay at home order, shelter in place restriction, or similar restriction in the past 14 days? *
Has you traveled outside of the US in the past 14 days? *
Are you currently waiting for a COVID-19 test result? *
Have you been directed to quarantine or isolated by Rhode Island Department of Health or a healthcare provider in the past 14 days? *
If you have answered "YES" to any of these questions, your dancer can not attend dance class. Please call the office to discuss a make up class.
I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosure. I understand that this document is to provide the best possible experience for dancers and staff at Cheryl's School of Dance. *
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