NWC/ AP Universal COVID-19 Screening and Attestation

NORTHWEST'S CHILD/AARON'S PLACE COVID-19 HEALTH SCREEN ATTESTATION:
To be conducted daily before access to NWC/AP facilities.

Your Name (Student/Staff coming to NWC/AP IN-PERSON facility) *

First Name Last Name

Date *

Date

Your role at NWC/AP *

Student Employee

SYMPTOMS OF COVID-19

Cough
Fever (above 100.4 ) or chills (before taking any medication to reduce the fever)
Shortness of breath or difficulty breathing
Unusual Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Do you have any of the SYMPTOMS OF COVID-19 above that are not attributable to another condition? *

YES NO

Within the past 5 days, have you had close contact with anyone that you know who had COVID-19 or COVID-19 like symptoms? Close contact is defined as being within 6 feet for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on), or the person lives in your household. *

YES NO

Have you had a positive COVID-19 test for active virus in the past 5 days? *

YES NO

Within the past 5 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? *

YES NO