COVID Fillable Form – Our House Chicago

Visitor Information

Visitor's Name (student or parent) *

First

Last

Date of Birth *

Questionnaire

Has the student/parent returned from any of the CDC Threat Level 3 or Level 2 countries within the last 14 days? *

No
Yes

Has the student/parent returned from any of the high risk states within the last 10 days? *

No
Yes

Has the student/parent had close contact with or cared for someone diagnosed with COVID-19 within the last 10 days? *

No
Yes

Has the student/parent experienced any cold or flu-like symptoms in the last 10 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? *

No
Yes

Signature *

Date *

Self Reporting Health Screening Questionnaire

Visitor Information

Questionnaire

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