COVID-19 HEALTH SCREENING

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COVID-19 Health Screening

(updated 11/20/2020)

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 YAS! 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, has anyone in your household (including siblings, nanny, caregiver) had a Covid-positive infection? *

YES NO

Have you (your student) 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

In the last week, have you (your student) 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 you (your student) have experienced two (2) or more of the symptoms listed above, on what date did they first begin? *

Submit

Home
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YAS! Parent Portal
2021 YAS! Calendar
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Contact
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