STAFF COVID-19 SCREENING QUESTIONNAIRE

Complete each day BEFORE you come to work.

The safety of East Pointe Dance and its staff and clientele is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite. Please do not enter the studio until your responses have been reviewed and your entry has been approved.

Please respond to each of the following questions truthfully and to the best of your ability.

Your participation is important to help us take precautionary measures to protect you and the other staff members and clientele.

Staff COVID-19 Form

STAFF COVID-19 SCREENING QUESTIONNAIRE

Complete each day BEFORE you come to work.

Are you currently experiencing, or have you experienced in the past 14 days, a fever (100.4° F/37.8° C or greater as measured by an oral thermometer)? *

Are you currently experiencing, or have you experienced in the past 14 days, a cough, shortness of breath or difficulty breathing, sore throat, new loss of taste or smell, chills, head or muscle aches, nausea, diarrhea, or vomiting?? *

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

Have you been tested for COVID-19 and are waiting to receive test results? *

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *

In the past 14 days, have you been on a commercial flight to a high risk state or traveled outside of the United States? *

In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight to a high risk state or traveled outside of the United States? *

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation. *

Consent of Initials *