COVID-19 HEALTH SCREENING

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COVID-19 HEALTH SCREENING

(updated 1/15/2021)

Please complete and submit the health screening questionnaire below. This questionnaire must be completed and submitted by every student and staff member before every instance of entering any PMT Productions facility, regardless of when you last entered the facility (once every 24 hour period).

For a complete list of our COVID-19 Procedures, visit pitchmethis.com/covid-19.

CoVID-19 Health Screening QUESTIONNAIRE

* Indicates required field

Name (Student Name) *

First

Last

Date *

In the last 2 weeks, have you or anyone in your household (for students: including siblings, nanny, caregiver) had a Covid-positive infection? *

YES NO

If applicable, please list the date of the first positive Covid-19 test? *

If you tested positive, you will not be allowed to enter the facility and may only return after two consecutive negative Covid-19 tests (PCR only) OR 10 days after the first positive Covid-19 test, if asymptomatic. If symptomatic, you must be symptom-free for 3 days before returning. If someone in your household tested positive, you will not be allowed to enter the facility and may only return 10 days after their first positive Covid-19 test AND after a negative Covid-19 test for yourself (PCR only).

Have you scheduled or do you plan to schedule a Covid-19 screening test, even if only as a precautionary measure, because of suspected exposure? *

YES NO

If applicable, please list the date of the schedule Covid-19 test. *

If a Covid-19 screening test is planned because of suspected exposure, you will not be allowed to enter the facility and may only return after a negative Covid-19 test (PCR only)—and at the discretion of the PMT Admin Team.

In the last week, have you experienced any of the following symptoms?

| Coughing, not related to allergies or asthma *

YES NO

| Loss of taste or smell *

YES NO

| Fever greater than 100.4 F in the last 24 hours *

YES NO

| Sore throat *

YES NO

| Nasal congestion, not related to allergies *

YES NO

| Unusual shortness of breath *

YES NO

| Diarrhea *

YES NO

| Nausea or vommiting *

YES NO

If two (2) more of these symptoms have been experienced, you will not be allowed to enter the facility and may only return after two consecutive negative Covid-19 tests (PCR only) OR 10 days after the onset of symptoms—and at the discretion of the PMT Admin Team.

On what date did the symptoms first begin? *

Submit