As a client and / or employee of Open Space, your health and safety are very important to all of us here. In an effort to prevent the spread or potential exposure of COVID-19, please review the below health screen questions. This questionnaire must be completed each day upon arrival to the program. The completed, signed and dated screening will be kept on file and be kept confidential.
Date (required)
Child's / Employee's Name (required)
Child's / Employee's Temperature (required)
I do not currently have, my child does not currently have, nor anyone in my household has potential symptoms of COVID-19 nor have a confirmed case of COVID-19. Symptoms include, but are subject to change and based on information from the CDC.
• Fever > 100.4 degrees TrueFalse • cough TrueFalse • shortness of breath TrueFalse • fatigue TrueFalse • muscle or body aches TrueFalse • headaches TrueFalse • new loss of taste or smell TrueFalse • sore throat TrueFalse • congestion / runny nose TrueFalse • nausea / vomiting TrueFalse • diarrhea TrueFalse
I have not, my child has not nor has anyone in my household had close contact with someone who tested positive for (within the last 14 days) or is currently being tested for COVID-19. "Close contact" is defined as any individual who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset or, for asymptomatic patients, 2 days prior to positive specimen collection. TrueFalse
I have not given my child nor has anyone in my household taken any medicine to lower his / her temperature. If I have given my child any medicine within the last 24 hours, the reason is notated below in additional comments/questions. TrueFalse
I have limited the number of people I come into contact with, I am practicing social distancing and I am abiding by the “Phase 4” instructions and regulations mandated by Gov. Pritzker and Mayor Lightfoot to prevent the spread of COVID-19. TrueFalse
I, my child, and everyone in my household is observing and adhering to the travel policy as outlined on the city of Chicago's website and Open Space's Response to Covid-19 document. This includes being tested and providing results to Open Space for all family members and/or observing a 10-day quarantine where necessary. TrueFalse
Parent / Guardian or Employee Name (required)
Emergency contact name and phone number (required)
Parent / Guardian or Employee Signature (required)
Additional Comments / Questions
