COVID-19 Daily Health Screening

Please complete and submit the form below prior to entering facility each day.

Participant's Name *

First

Last

Parent's Name *

First

Last

Today's Date *

Email *

Phone *

Have you (Participant) been ill with a fever, chills, cough or body aches in the last 14 days? *

Yes
No

Has anyone in your household had these symptoms in the last 14 days? *

Yes
No

Have you or anyone in your household traveled internationally in the last 14 days? *

Yes
No

Have you (Participant) or anyone in your household traveled to a location in the US where an increase of incidences of COVID-19 has been reported in the last 14 days? *

Yes
No

NOTE: If a visitor has traveled to any state on the travel advisory list as specified on the covid19.nj.gov website, we are asking you to stay away for a period of 14 days. After that time you may fill out the form again and enter our facility.

Have you (Participant) been told by a healthcare provider that you should self-quarantine due to potential COVID-19 exposure or you are suspected of having COVID-19? *

Yes
No

Who is filling out this form? *

If you are an adult filling out this form for a minor, what is your relation to the child: parent, guardian, grandparent etc. If an adult filling the form out for self, simply place your full name.

By checking the box below, you agree that your statements are all true to the best of your knowledge. *