COVID-19 Visitor Screening Questionnaire

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Name of the person completing the questionnaire. *

Please respond to each of the following. *

Yes

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

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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