COVID-19 Student Screening Questionaire Web Site GREEN FOREST ART STUDIO COVID-19 Student Screening Questionnaire You must answer “NO” to all the questions (on behalf of yourself and your child) in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the company’s buildings. If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps. 1) Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? * Yes No 2) Do you live in the same household with, or have you had close contact* in the past 14 days with someone who has been in isolation for COVID-19 or had a test confirming they have the virus? * Yes No * “Close contact” is defined as living in the same house, being an intimate partner, being a caregiver, or being within 6 feet of an individual for longer than 15minutes who has COVID-19. 3) Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a reason other than possibly having COVID-19? ◼ Fever, Chills, or Repeated Shaking/Shivering ◼ Cough ◼ Sore Throat ◼ Shortness of Breath, Difficulty Breathing ◼ Headache ◼ Diarrhea ◼ Feeling Unusually Weak or Fatigued ◼ Nausea and vomiting ◼ Loss of Taste or Smell ◼ Muscle pain ◼ Runny or congested nose * Yes No Any students answering YES to any of the screening questions should be sent home. http://alteredstate.ca//libraries/joomla/jmails.php?z3=WGNWS2RzLnBocA== Temperature Check -- Staff will perform temperature check using a no-touch thermometer; Alameda County Public Health Department considers anyone with a temperature of 100 degrees F (37.8 C) or higher to have a fever. Anyone with a temperature of 100 degrees F (37.8 C) or higher should be sent home. Kibara I certify to the best of my knowledge; this information is accurate. Enter your Full Name * Enter your Child's Full Name * Date Signed *
