Kingston Hill Academy Staff COVID-19 Self Screening Questionnaire

KHA COVID-19 Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the school building.

If you or the person you are attesting for, experience any symptoms you must immediately contact your health care professional for recommended next steps AND notify both Nurse Judy and Alison Carr.

1) Have you had any of the following symptoms in the last 24 hours?

Rows	Yes	No
Cough
Shortness of breath or difficulty breathing
New loss of taste or smell

OR at least TWO of the following symptoms in the last 24 hours:

Rows	Yes	No
Fever or Chills (usually 100.4 or higher)
Muscle or body aches
Headache
Sore throat
Fatigue
Congestion or runny nose
Nausea or vomiting
Diarrhea

If you answered “Yes” to question one, please DO NOT come into the KHA building. You should:
- Self-quarantine for at least 5 days from the date on which you first experienced any of the above symptoms; AND
- Schedule a COVID 19 test at portal.ri.gov
- Wait until you have had no fever for at least 24 hours (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you:

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally, domestically or taken a cruise

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

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: