LSCC COVID-19 Pre-Screening All Staff and Volunteers must complete this form no more than 12 hours before participating in LSCC related activities that include potential physical interactions with others. Name* First Last Date Date Format: MM slash DD slash YYYY Do you have any of these symptoms that are not caused by another condition? Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, Recent loss of taste or smell, Sore throat, Congestion, Nausea or vomiting, or Diarrhea*YesNoWithin the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms?YesNoContact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on). Have you had a positive COVID-19 test for active virus in the past 10 days? YesNoWithin the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? YesNoIf you answered yes to any of these questions, please do not attend! We will work with you to figure out someone to take your place.PhoneThis field is for validation purposes and should be left unchanged.
