2023 Health Questionnaire

This form must be completed up to 14 days prior to attending any class.

Due to Covid-19, Influenza, RSV and other serious communicable disease’s capacity to transmit from person-to-person through respiratory droplets, the government will on occasion set recommendations, guidelines, and some prohibitions which Clallam Mosaic complies with. Mosaic’s practices are flexible and will evolve based on medical/government recommendations and best practices for maintaining a healthy environment.

Name of Participant*

First NameLast Name

Name of Person completing the form

First NameLast Name

Email*

example@example.com

Potential Serious Communicable Disease Symptoms:

● Elevated temperature or fever of 99.5°F or higher
● Cough or sore throat
● Vomiting or diarrhea
● Shortness of breath and/or difficulty breathing
● Loss of smell and/ or taste
● Fatigue, muscle aches, chills, or shaking
● Persistent headaches

YesNo

Participant consistently wears a mask when symptoms are present or directed.Participant practices social distancing when needed or directed outside the home.Participant washes hands regularly.Participant does not share food, personal hygiene or other items that could spread the virus with individuals outside of household.Participant practices health safety measures in large group gatherings, either indoor or outdoor.All care providers who come in and out of participant's home practice appropriate pandemic safety measures - mask usage, hand washing, etc.Participant does not do any of the above.

Signature

For new participants, the following forms are needed:

Fill out once for 2023:

2023 In-Person Intake Form
2023 Health Status Form
2023 Health Liability Release Waiver
2023 In-Person Code of Conduct
2023 Participant Consent Form

Filled out each Term:

The appropriate term's Registration Form

Clallam Mosaic Health Questionnnaire