ACDS COVID-19 Self Screening Questionnaire

Student 1, Employee or Visitor Name *

First Name Last Name

Student 1 Grade

Student 2

First Name Last Name

Student 2 Grade

Student 3

First Name Last Name

Student 3 Grade

Student 4

First Name Last Name

Student 4 Grade

Symptoms in Individual or any Member of the Household

*

Yes

No

Has anyone in your household had a temperature of 100 degrees Fahrenheit or higher when taken by mouth in the last 24 hours?

Has anyone in your household had any of the following symptoms in the last 24 hours that are not caused by an underlying condition or allergies/asthma: Chills or sweating, new or worsening cough, sore throat, runny nose/congestion, chest pain or pressure, aching throughout the body (not related to an injury), vomiting or diarrhea, loss of taste or smell, other lower respiratory symptoms, or aches and pain that are new or unusual?

If you answered “yes” to any of these questions, the student or employee must stay home and you should consult a healthcare professional. Return to school will be determined in alignment with the recommendation of a healthcare provider and CDC guidelines. Please contact your Division Head or the Head of School to notify ACDS of the absence and discuss the steps in returning to school.

Close Contact / Potential Exposure

In the last 14 days, has the ACDS student or employee: *

Yes

No

1. Had close contact (within 6 feet for at least 15 minutes cumulatively over 24 hours) with a person with confirmed COVID-19 during their infectious period (2 days prior to and 10 days following onset of symptoms or date of positive test if asymptomatic).

2. Had close contact with someone who is waiting for the results of a COVID-19 test?

If you answered "yes" to question 1 the student or employee must self-quarantine for 14 days in accordance with CDC guidelines.

If you answered "yes" to question 2, the student or employee must stay home until the results of the test are known.

Individual High-Risk Behavior

Has the ACDS student or employee engaged in any of the following high-risk behaviors over the last 14 days: *

Yes

No

1. Did you attend large social gatherings or events or otherwise been in crowds were people were not wearing masks or it was not possible to socially distance?

2. Did you travel by any means other than your own personal vehicle, such as a plane, ride-share, bus, or train?

3. Were you on a cruise ship?

4. Have you been to a location where it was not possible to maintain distance from people with moderate/high or unknown exposure risks?

If you answered "yes" to any of these questions the student or employee must self-quarantine for 14 days. Alternatively, students or employees may return after a 7-day quarantine if they are symptom-free and have a negative PCR test administered on day 5 or later.

I certify to the best of my knowledge; this information is accurate.

Date *

Date

Signature *

Clear

Parent Name (if filing out form on behalf of child(ren))

First Name Last Name