River Valley Club Health Screening

To protect everyone in our community, all persons stepping on campus at FitKids Childcare and the River Valley Club must submit the following questionnaire.

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* 1. Your name

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* 2. Date

Date/Time

Date

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* 3. Temperature Reading

Above 100* F

Below 100* F

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* 4. Name of personnel who took temperature reading

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* 5. Do you have one or more of the following symptoms: Feverish in the last 72 hours (without fever reducing medication), runny nose, sore throat, cough, shortness of breath, muscle aches, chills, any change in sense of taste or smell. Have you had any of these symptoms in the last 14 days?

Yes

No

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* 6. In the last 14 days, have you had contact with someone with a confirmed diagnosis of COVID-19, or who is under investigation for COVID-19, or is ill with respiratory illness?

Yes

No

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* 7. In the last 14 days, have you travelled outside of New Hampshire, Maine, or Vermont?

Yes

No