Visitor Health Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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

Name *

Phone Number *

Address

Reason for visit *

Are you experiencing any of these symptoms? *

Fever or Chills

Cough

Headache

New loss of taste or smell

Sore Throat

Shortness of breath/ difficulty breathing

Fatigue

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) *

Yes

Have you traveled in the past 14 days to any regions affected by COVID-19? *

Yes

Have you been tested for COVID-19?

Yes

Clear selection

Have you been diagnosed with COVID-19?

Yes

Clear selection

Date of visit

YYYY

Time of visit

Time

Clear form

Never submit passwords through Google Forms.

This form was created inside of Burch Charter School of Excellence. Report Abuse

Forms