COVID19 QUESTIONNAIRE | ICTALENT DANCE

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COVID-19 SCREENING QUESTIONNAIRE

Full Name

Gender *

MALE

FEMALE

Date

Please assist us to mitigate the spread of COVID-19. Please an x in the box to indicate your response.

Screening Questions

1. Have you or anyone you have had contact with travelled out of the USA in the last 14 days? *

YES

2. Have you or anyone you have had contact with travelled within the USA in the last 14 days? *

YES

3. Have you or anyone you have had contact with has or had a bad cough within the last 14 days? *

YES

4. Have you or anyone had contact with has or had a fever/flu within the last 14 days? *

YES

5. Have you had any shortness of breath within the last 7 days? *

YES

6. Are you currently experiencing a fever over 100, difficulty breathing or cough? *

YES

7. Have you attended any events or gathering with more than 100 people within the last 7 days? *

YES

8. Have you been in close contact with a person known to have the Corona Virus? *

YES

9. Have you or anyone you have had contact with been asked to self- quarantine? *

YES

Have you been tested for Covid-19? *

YES

If so, what were the results?

NEGATIVE

POSITIVE

Weekly Temperature

I have read and answered all questions TRUTHFULLY, regarding COVID-19.

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