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Hope Academy COVID-19 Visitor Compliance & Questionnaire Form
You must certify that you agree to all of the following to enter the facility.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Recorded Temperature Results
*
I am not exhibiting any symptoms related to COVID-19, i.e. a fever, cough, sore throat, chills, shortness of breath.
*
Agree
Disagree
I have not had any person-to-person contact with someone who has exhibited COVID-19 symptoms in the last 14 days.
*
Agree
Disagree
I have not visited an area where there has been a significant outbreak of COVID-19 activity in the last 14 days.
*
Agree
Disagree
If previously diagnosed with COVID-19, I agree that I have had no fever for at least 72 hours (that is three full days of no fever without the use of medicine designed to reduce fever); AND other symptoms have improved (i.e. cough and/or shortness of breath have improved); AND at least 14 days have passed since the initial diagnosis.
*
Agree
Disagree
I agree to abide by the policies of Hope Academy’s on social distancing, handwashing and respiratory etiquette at all times when I am in the facility.
*
Agree
Disagree
Signature
*
Submit
Should be Empty: