COVID-19 Screening Questionnaire
Camp Jefferson's COVID-19 Screening Questionnaire. This form must be filled out each day before the camper can be dropped off.
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Camper's Name (first and last) *
Camper's Group
Today's Date *
Have you traveled in the last 14 to 30 days? *
If you answered yes, where have you traveled and when? (include date of arrival & departure)
Have you encountered or had close contact exposure to a person known to be infected with novel coronavirus (COVID-19)? *
Have you experienced any of these symptoms: *
* Fever may be subjective (no temperature taken with thermometer); if non-specific fever is reported, decline appointment and refer individual to their health care provider.
Date symptom began
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