C19 Screening Questions

COVID-19 Self Screening Questions
Please complete this form for your family who will be attending Co-Op each week.
Family Name*
You must be able to answer “NO” for each member of your household to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come to or enter the Co-Op/Church building.
If you experience any symptoms or answer “YES” to any of these questions, you should immediately contact your health care professional for recommended next steps AND notify the Band Director.

1) Are any members of your household experiencing any of the following symtoms now or within the past 48 hours?*

	Yes	No
Fever (usually 100.4 F or higher)
Chills
Repeated shaking with chills
Cough (new or worsening of exisiting cough)
Shortness of breath or any difficulty breathing
Muscle pain
Headache
Sore throat
New loss of taste or smell
GI upset or diarrhea
Any other flu-like symptoms

If you answered “Yes” to any part of question one for any member of your household, please DO NOT come into Co-Op. Your entire household should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 14 days has any member of your household:*
Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
If you answered “Yes” to any part of question two for any member of your household, please DO NOT come into Co-Op. Your entire household should self quarantine for at least 14 days.
I certify to the best of my knowledge; this information is accurate.
Date*
MonthDayYear
Date
Should be Empty:

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

COVID-19 Self Screening Questions