COVID-19 Visitor Screening Questionnaire
Name of the person completing the questionnaire. *
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?
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. *
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