E3 COVID-19 Self Screening Questionnaire

1
Why are you visiting today?* This field is required.
Student
Coach/Mentor
Parent
Visitor
Employee
2
Team NumberPlease enter your Robotics Team Number
3
Date* This field is required.
Date
Month
Day
Year
4
Name* This field is required.
First Name
Last Name
5
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 come enter the company’s buildings.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your coach and E3RC Staff
6

In order to remain open to in-person visitors, per the State of Indiana, all people must wear a face covering at all times when another person is present.
This should be a minimum of a cotton mask or a full face shield.

If you need a mask they are available for $1.00
7
I AGREE to wear a face covering while at E3RC
YESNO
8
1) Have you had any of the following symptoms in the last 24 hours?* This field is required.
Yes
No
Cough
Shortness of breath of difficulty breathing
Cough
Shortness of breath of difficulty breathing
Yes
No
Yes
No
1 of 2
9
OR at least TWO of the following symptoms in the last 24 hours:* This field is required.
Yes
No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 7
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If you answered “Yes” to question one, please DO NOT come into E3. You should:

Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND

Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND

Improved respiratory symptoms (no cough, shortness of breath)
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2) In the last 14 days have you:* This field is required.
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 or taken a cruise
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
Yes
No
Yes
No
Yes
No
1 of 3
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If you answered “Yes” to any part of question two, please DO NOT come into E3. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
13
Signature* This field is required.
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