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: email@example.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
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?
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?
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?
*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.