Please complete prior to arriving Pre-screening for 1341 N Delaware Ave., Philadelphia, PA If possible, please complete this form at least 15 minutes prior to entering the building. Phone*I am completing this form:* For myself As a representative parent/guardian/caregiver First name of person being checked in:* Last name of person being checked in:*Throughout this form, "you" will refer to the person listed here. Around what time to you anticipate arriving today?* : Hours Minutes AM PM AM/PM 1. Have you experienced any of the following symptoms in the past 48 hours:*• 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 vomiting • diarrhea Yes No 2. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?* Yes No 3. Have you been in close physical contact in the last 14 days with anyone who has tested positive and/or has symptoms consistent with COVID-19?* Yes No 4. Are you currently waiting on the results of a COVID-19 test?* Yes No 5. Have you traveled out of the country in the past 10 days?* Yes No Verification* By checking this box, I attest that I have completed this form truthfully to the best of my knowledge. Δ
