COVID-19 Visitor Screening Questionnaire
* Required
Name of the person completing the questionnaire.
*
Your answer
Please respond to each of the following.
*
Yes
No
Do you have an unexplained cough, difficulty breathing, sore throat, loss of taste or smell?
Have you had close contact with an infected person (COVID-19) within the previous 14 days?
Have you had a fever of 100.4 or greater within the last 48 hours?
Have you or a member of your household tested positive for COVID-19 in the past 10 days?
Have you been tested for COVID-19, and are awaiting tests results?
Yes
No
Do you have an unexplained cough, difficulty breathing, sore throat, loss of taste or smell?
Have you had close contact with an infected person (COVID-19) within the previous 14 days?
Have you had a fever of 100.4 or greater within the last 48 hours?
Have you or a member of your household tested positive for COVID-19 in the past 10 days?
Have you been tested for COVID-19, and are awaiting tests results?
If you answered "Yes" to any of the questions above, please provide further clarification/details below and contact Mrs. Carlton or Mr. Blaxton for further guidance. If you answered "No" to each of the questions above, simply state N/A here.
*
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Northeast Arkansas Education Cooperative.
Report Abuse
Forms
