If you attend or work at NCP and think you have been exposed to Covid-19 or have been tested for Covid-19, please print out this questionnaire, answer all sections and email it to Carol Zartman: carolzartman.ncns@gmail.com

NCP COVID-19 Questionnaire for Staff and Students

Name of Staff or Student: ____________________________________________

Last date the person listed above was in the building (2660 Lititz Pike):

____________________________________________________________________

Has the staff/student above been experiencing symptoms* consistent with COVID-19?                                                                                                                                                            Yes                    No

If yes:

On what date did symptoms* first begin? _____________________________                                                    

Has the staff/student had or have a scheduled COVID-19 test? ___________________________                            Yes             No

If yes, what is the date of the test?__________________________________

Has the staff/student tested positive for COVID-19?                               

Yes No

If yes:

On what date did the COVID-19 test take place?_______________

Does  the staff/student have symptoms*?                                                                Yes             No

If yes, what is the date of the onset of symptoms*? _______________                                                       

Has the staff/student been exposed to someone who has tested positive for COVID-19, or have you been exposed to someone who is a probable case (likely positive) and/or being tested for COVID-19?

Yes No

If Yes,

Does this positive or probable person live in the  same home?                              Yes             No

What was the first date of symptoms* for this  person? ___________                                                          

What is the date of this person’s COVID-19  test?    ____________                                                        

Has the staff/student traveled outside of PA for longer than a 24-hour period?

Yes             No

*COVID-19 symptoms incude, but are not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vommitting, and diarrhea.

If you have answered “yes” to any of the bold questions above, please quarantine for the safety of others. A Neffsville Preschool board member will be in contact with you to discuss your next steps. Thank you for your diligent help in preventing the spread of COVID-19.

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