Discovery Programs Covid-19 Health Questionnaire (As of June 9th, 2020)
As required by the Protocols of Discovery Programs (as modified from time to time, the "Protocols"), this form must be filled out every time your child attends class, on the day of their class and at least 30 minutes before the start time of their class. If you or a caregiver plans to attend a class with the child, the Health Questionnaire must also be filled out separately for the parent/caregiver.
I am filling out this form for:
Child's Last Name
Child's First Name
Your First and Last Name
Has your child [or have you, if you are filling out this Questionnaire for yourself] experienced any of these unexplained symptoms within the last 10 days?
Fever of 100.4 or higher or Chills
Shortness of Breath
Loss of Taste or Smell
Vomiting or Nausea
Runny nose or Congestion
Muscle Aches and Pains not associated with exercise or strenuous activity
Has your child [or have you, if you are filling out the Questionnaire for yourself] had a positive Covid-19 test (saliva or nose or throat swab) in the past 10 days?
Has your child [or have you, if you are filling out the Questionnaire for yourself] been in close contact with someone or do they/you live with someone who has a confirmed or suspected Covid-19 case (someone that is experiencing the symptoms above or waiting on a test result) in the past 10 days?
Is your child [or you, if you are filling out this Questionnaire for yourself] in quarantine due to exposure to someone with Covid-19?
If your child [or you, if attending class] is [are] experiencing new unexplained symptoms as indicated in your answers above or you have answered yes to any of the other questions, your child may not attend camp/class. We refer you to the Protocols for further information in this regard. We advise that you see your health care provider and it is imperative that you let us know if your child or you attended class while they or you may have had previous Covid-19 exposure. You may call us at 212-749-8717 or email us at email@example.com to discuss this further. Discovery is obligated to report any positive Covid-19 cases to the NYCDOH.
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