COVID-19: On-Site Health Screening Form

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.
Name
First NameLast Name
Date:
MonthDayYear
Date
Time:
Temperature ˚F
Do you have any of the following symptoms:
Fever within the past 24 hours?*
YesNo
Coughing/Sneezing?*
YesNo
Chills?*
YesNo
Muscle Pain?*
YesNo
Sore throat?*
YesNo
Nausea/Vomiting?*
YesNo
Diarrhea?*
YesNo
New loss of taste or smell?*
YesNo
Shortness of breath?*
YesNo
If you answered yes to any of the above questions, please explain.
And/or any of the following within the past 14 days:
In the last 72 hours, I/family member in my household was ill.*
YesNo
In the last 14 days, I/family member have traveled inter-island or out of state?*
YesNo
Have you or anyone in your household been in contact with people infected, or diagnosed with COVID-19?*
YesNo
Do you reside in a community where community-based spread of COVID-19 is occurring?*
YesNo
If you answered yes to any of the above questions, please explain.
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 ?*
YesNo
Parent Signature
Clear
Should be Empty:

COVID-19 On-Site Health Screening Form