VISITOR'S HEALTH SCREENING QUESTIONNAIRE
The SEED School of Maryland has implemented new required protocols, to minimize risks of the spread of COVID-19 in our school community. Any person entering a school facility is subject to completing a health screening by answering the questionnaire published below.

Reason for Policy:
Helps determine the wellness of individuals on our campus and helps to prevent the spread of COVID-19.  This policy is in effect until a return to normal operation in accordance with all public health and governmental orders.

Health Screening Questionnaire:

The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are requiring visitors to complete and submit this questionnaire prior to entering SEED facilities.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and the SEED community.
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Date *
MM
/
DD
/
YYYY
Last Name: *
First Name: *
Phone Number (Mobile/Home): *
Email Address *
Campus Area: *
1.  Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)
*
No
Yes
A. Fever
B. Cough
C. Shortness of Breath
D. Sore Throat
E. Fatigue
F. New Loss of Taste or Smell
G. Chills
H. Head of Muscle Aches
I. Nausea or Vomiting
J. Diarrhea
2. Has any health department or health care provider been in contact with you and advised you to quarantine? *
No
Yes
Select No or Yes
3. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
No
Yes
Select No or Yes
4. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
No
Yes
Select No or Yes
5. Have you been tested for COVID-19 and are waiting to receive test results? *
No
Yes
Select No or Yes
6. Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *
No
Yes
Select No or Yes
7.  In the past 14 days, have you traveled outside of the state of Maryland or the United States? *
No
Yes
Select No or Yes
If "Yes", please explain:
8. In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the state of Maryland or the United States? *
No
Yes
Select No or Yes
9. Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the workplace?  If “yes”, please provide a brief explanation. *
No
Yes
Select No or Yes
If "Yes", please explain:
Certification
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
Signature - Please type your name. *
Note;
Note: The information collected on this form will be used to determine whether you may be infected with COVID-19 and to determine your access to SEED facilities. The information on this form will be maintained as confidential. Any questions should be directed to the The SEED School of Maryland's Chief of Staff (410-843-9477 Ext 221).
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