COVID-19 Screening Questions 2020-21 – Indianapolis Adult Education

Name*

First Last

Cell Phone*

Email*

Please select your building location:*

Please answer the following questions:

Have you recently been within 6 feet of a person with a lab-confirmed case of COVID-19, or a person who has exhibited multiple COVID-19 Symptoms in the last 14 days?*

Yes
No

In the past 72 hours, have you experienced a fever of 100 degrees or above?*

Yes
No

In the past 72 hours, have you experienced unusual or new shortness of breath, trouble breathing or severe wheezing?*

Yes
No

Have you recently traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department? Including China, Italy, Iran, Brazil, and countries in Europe?*

Yes
No

In the past 72 hours, have you experienced unusual or new muscle pain?*

Yes
No

In the past 72 hours, have you experienced unusual or new chills or repeated shaking with chills?*

Yes
No

In the past 72 hours, have you experienced an unusual or new loss of smell or taste, or a change in taste?*

Yes
No

In the past 72 hours, have you experienced an unusual or new cough?*

Yes
No

In the past 72 hours, have you experienced an unusual or new sore throat?*

Yes
No

In the past 72 hours, have you experienced unusual or new nausea, vomiting, or diarrhea?*

Yes
No

In the past 72 hours, have you experienced an unusual or severe headache?*

Yes
No