ELC Pre-screen Questionnaire | The Suquamish Tribe

Name of Person Being Screened*

If you are filling this out for a child, use THEIR NAME

First Last

Within the past 14 days, has this individual been named a close contact (6 feet or closer for at least 15 minutes) to a person who is known to have laboratory-confirmed COVID-19?*

Yes
No

ALERT: This individual needs stay home. Please contact the child’s teacher or the employee’s supervisor (whichever applies), and/or the school nurse.

Please contact the school nurse at 360-394-8589 if you have any questions.

Within the past 14 days, has this individual been in close physical contact with a person who is a “probable” case? Probable case: someone who is exhibiting COVID-19 symptoms AND is a close contact to a confirmed COVID-19 case. (This is a person who should be in quarantine already because of their exposure to a positive case, and is awaiting COVID-19 results. If this person’s COVID-19 results come back negative, their close contacts may resume normal activities.)*

Yes
No

ALERT: This individual needs to stay home until the close contact receives their COVID-19 test result.

Please contact the school nurse at 360-394-8589 if you have any questions.

Has this individual had any of the following symptoms in the last 14 days, or since last screened? (whichever is most recent)*

Cough
Shortness of breath or difficulty breathing
Fever of 100.4 degrees F or above
New loss of taste or smell
None of the above

ALERT: This individual needs to stay home. Please contact the child’s teacher or the employee’s supervisor (whichever applies), and/or the school nurse. If the individual has already tested negative for COVID-19, please refer to our normal Illness Exclusion Policy. If the individual does not fit the criteria for illness exclusion for this symptom, the individual is cleared to enter ELC buildings.

Please contact the school nurse at 360-394-8589 if you have any questions.

Has this individual had any of the following symptoms in the last 14 days, or since last screened? (Whichever is most recent.)*

Runny nose/Congestion
Fatigue
Headache
Sore throat
Muscle or body aches
Nausea or vomiting
Diarrhea
None of the above

ALERT: If you've selected one symptom: Refer to our normal Illness Exclusion Policy. If the individual does not fit the criteria for illness exclusion for this symptom, the individual is cleared to enter our ELC buildings.

If you've selected two or more symptoms: This individual needs to stay home. Please contact the child’s teacher or the employee’s supervisor (whichever applies), and/or the school nurse. If the individual has already tested negative for COVID-19, please refer to our normal Illness Exclusion Policy. If the individual does not fit the criteria for illness exclusion for this symptom, the individual is cleared to enter ELC buildings.

Please contact the school nurse at 360-394-8589 if you have any questions.

Phone

This field is for validation purposes and should be left unchanged.

ELC COVID Pre-screen Questionnaire