Volunteer COVID-19 Self Screening Questionnaire

Volunteer COVID-19 Self Screening Questionnaire

For Mountain Sage Community School
Thank you for taking the time to complete the self screening symptom check. As a small school we need to take extra precaution to ensure the safety of our community. Due to new Larimer County Department of Health and Environment guidance, volunteers who test positive would count toward the number of cases in a classroom or the school when determining pre-outbreak or outbreak status. Because of this, it is essential you complete this form before coming to school each time you are scheduled to volunteer.
Name

First Name Last Name
Reason for volunteering
Example: lunch service, 4th grade nature walk, etc.

1) Are you currently experiencing, or have you experienced in the past 24 hours, any of the following symptoms? *

	Yes	No
New or worsening cough
Shortness of breath of difficulty breathing
New loss of taste of smell
Fever of 100 or higher
Sore throat
Runny nose or congestion
Muscle or body aches
Headache
Fatigue
Nausea or vomiting
Diarrhea

2) What is your current temperature?
Fevers over 100 degrees are not permitted at Mountain Sage.
If you answered “Yes” to any of the symptoms mentioned above you may not come in to volunteer. Please contact:
- the teacher if volunteering with a class
- Hillary Mizia if volunteering with lunch service
- Jilli Jackson if volunteering in the garden
- Holly Thompson-Bandong if volunteering in the library, or
- Sarah Cooper if you are unsure who to contact.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: