Health Screening for CFF TUESDAY Night Class

This FORM, or a PAPER FORM, must be completed and submitted before you or your children may enter the Parish School Building, before EVERY CLASS.

Additionally, please note that you must inform the parish if you or any family member is planning to, or has already traveled to any state that has a positive rate of more than 10% for COVID.
The following website provides information regarding the positivity rate for all 50 States, US Territories, and popular international destinations.

https://coronavirus.jhu.edu/testing/testing-positivity

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* 1. What is your family's last name?

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* 2. Do you, if attending yourself, or your child have a temperature of 100.4 or more at the time of completing this screening?

No.

Yes.

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* 3. If you answered YES, write the name of the person(s) who are ill.

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* 4. Since the last time on campus, have you, if attending yourself, or your child had any of the following symptoms: Cough, shortness of breath, difficulty breathing, new loss of taste or smell, fever of 100.4 or higher (measured or subjective), chills or shaking chills, muscle aches, sore throat, headache, nausea or vomiting, diarrhea, fatigue, and congestion or runny nose?

Yes

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* 5. IF you answered yes to #2, please write the name of the person(s) affected, and the symptoms experienced.

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* 6. Since the last time on campus, have you, if attending yourself, or your child been waiting for a COVID-19 test result, been diagnosed with COVID-19, or been instructed by any health care provider or the health department to isolate or quarantine?

Yes

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* 7. IF you answered yes to question number 5, write the name of the person(s) here.

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* 8. In the last 14 days, have you, or your child had close contact (within 6 feet for at least 15 minutes) with anyone diagnosed with COVID-19 or suspected of having COVID-19?

Yes

Health Screening for CFF TUESDAY Night Class

Question Title

* 1. What is your family's last name?

Question Title

* 2. Do you, if attending yourself, or your child have a temperature of 100.4 or more at the time of completing this screening?

Question Title

* 3. If you answered YES, write the name of the person(s) who are ill.

Question Title

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* 5. IF you answered yes to #2, please write the name of the person(s) affected, and the symptoms experienced.

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* 6. Since the last time on campus, have you, if attending yourself, or your child been waiting for a COVID-19 test result, been diagnosed with COVID-19, or been instructed by any health care provider or the health department to isolate or quarantine?

Question Title

* 7. IF you answered yes to question number 5, write the name of the person(s) here.

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* 8. In the last 14 days, have you, or your child had close contact (within 6 feet for at least 15 minutes) with anyone diagnosed with COVID-19 or suspected of having COVID-19?

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* 9. If yes, write the name(s) of the family members who were exposed, here.