Visitor Health Questionnaire
Instructions: Prior to arriving to Burch Charter School, the following health monitoring questionnaire must be
completed by all visitors. Completing the questionnaire is a requirement along with the following measures:
Temperature Check
Mandatory Face Mask
Sanitized Hands
Social Distancing
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Name *
Phone Number *
Reason for visit *
Are you experiencing any of these symptoms? *
Fever or Chills
New loss of taste or smell
Sore Throat
Shortness of breath/ difficulty breathing
Muscle or body aches
Congestion or runny nose
Nausea or vomiting
GI or Diarrhea
None of the Above
Check all the symptom boxes that applies to how you feel today.
In the past 14 days, have you been in close contact with an infectious individual diagnosed with COVID-19 or have you been advised to quarantined by a Public Health Official? (close contact is defined as within 6 ft for 10 min or longer) *
Have you traveled in the past 14 days to any regions affected by COVID-19? *
Have you been tested for COVID-19?
Clear selection
Have you been diagnosed with COVID-19?
Clear selection
Date of visit
Time of visit
Clear form
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