St. Luke Health Screen Attestation FORM TRANSFER

COVID-19 HEALTH SCREEN ATTESTATION:

To be conducted daily before access to the St. Luke School campus
Your Name (Person coming to campus) *

First Name Last Name
Date *

Month Day Year
Date
What is your role at St. Luke School? *

Student Employee Visitor
SYMPTOMS OF COVID-19
- Cough
- Fever (above 100ºF) 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
What is your temperature? *

Below 100ºF Above or Equal to 100ºF
Within the past 14 days, have you had close contact with anyone that you know who had COVID-19? 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 traveled outside of the state or internationally recently?

Yes No
Have you had a positive COVID-19 test for active virus in the past 10 days? *

Yes No
Within the past 14 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
Should be Empty:

COVID-19 HEALTH SCREEN ATTESTATION: