• COVID-19 On-Site Health Screening Form

    To be completed by participants upon arrival and departure of all in-person sessions with Kānehūnāmoku Voyaging Academy and its programs.
  • Date:
     / /
    2 digit month, 2 digit day, 4 digit year

  • Do you have any of the following symptoms:

  • Fever within the past 24 hours?*
  • Coughing/Sneezing?*
  • Chills?*
  • Muscle Pain?*
  • Sore throat?*
  • Nausea/Vomiting?*
  • Diarrhea?*
  • New loss of taste or smell?*
  • Shortness of breath?*

  • And/or any of the following within the past 14 days:

  • In the last 72 hours, I/family member in my household was ill.*
  • In the last 14 days, I/family member have traveled inter-island or out of state?*
  • Have you or anyone in your household been in contact with people infected, or diagnosed with COVID-19?*
  • Do you reside in a community where community-based spread of COVID-19 is occurring?*

  • If staff or visitors answer yes to any of these questions, you will be asked to isolate at home and to see a medical professional for advice. Documentation from a doctor or a COVID-19 test with a NEGATIVE RESULT may be requested prior to returning to in-person sessions.

    *All completed forms shall be saved.

  • My household continues to practice and follow state guidelines regarding COVID-19 ?*
  • Clear
  •  
  • Should be Empty: