Covid Form – Nelson CPR

Covid-19 Screening Form

Completing this form is required to attend any class If you are attending multiple classes, you only need to fill this once.

Student Name ^*:

Today’s Date ^*:

Temperature ^*:

Fahrenheit

1. Have you traveled outside of the USA in the last 14 days?

2. Have you traveled within the USA in the last 14 days?

3. Have you been on a cruise ship in the last 14 days?

4. Have you been in close contact with anyone who has traveled domestically or internationally in the last 14 days?

5. Have you attended any events or gatherings with more than 100 people?

6. Have you been in contact with a person known to have the 2019 Novel Coronavirus?

7. Have you been asked to self-Quarantine?

8. Do you currently have a fever or lower respiratory symptoms such as a cough or shortness of breath?

9. Do you have a new onset of cold symptoms such as a cough and runny nose?

P.O. Box 7775 Wesley Chapel, FL 33545, (813) 994-2646
www.nelsoncpr.com * nelsoncpr@verizon.net