CWS – COVID-19 QUESTIONNAIRE

COVID-19 Health Screening

The following questions will be asked of all participants.
⚠️ IMPORTANT ⚠️

THIS FORM MAY *ONLY* BE FILLED OUT
WITHIN 24 HOURS OF CLASS
AND NOT PRIOR TO THAT TIME.
Name of the Participant
Email *
example@example.com
Phone Number *
In the last two weeks, have you or any member of your family been in close contact with someone who has shown symptoms of COVID-19, has tested positive for COVID-19, or been diagnosed with COVID-19? *Close contact is when you are within 6 feet of an infected person for at least 15 minutes. *

YES NO
Do you, your child, or someone else in your household have any of the following symptoms? *

Fever Over 100.4°F Cough Difficulty Breathing Muscle Aches Sore Throat Vomiting Recent Loss of Taste or Smell Congestion or Runny Nose NO SYMPTOMS
Have you (the participant) been fully vaccinated against COVID-19?

YES - VACCINATED NO - UNVACCINATED
Additional Notes
Please upload a photo of your vaccination card — OR — Bring it With You to Class.

You will also be asked to present your card in class, to your instructors.
Cancel of
By signing this form, I hereby declare that the details furnished above are true and correct to the best of my knowledge. *

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COVID-19 Health Screening