COVID-19 Health Screening form COVID-19 Health Screening formAs a safety precaution for all users of PBT facilities, we require everyone to submit this health screening prior to entering the building/campus each day. Please answer the following questions prior to your arrival at PBT. If you answer YES to any of the health screening questions, you must stay home. If you answer YES to any of the health screening questions, discontinue the survey and follow Allegheny County Health Department guidance (https://www.alleghenycounty.us/Health-Department/Resources/COVID-19/COVID-19.aspx) for next steps. Please also email the School inbox, PBTSchool@pittsburghballet.org, to notify that you were unable to pass the health screening. You needn't give specific details, just that you were unable to pass the health screening.Name of Person Entering PBT today*If you are completing this on behalf of your child/dependent, indicate your child/dependent's name, and complete the form based on your child/dependent's status. First Last Class/Level*If you are completing this on behalf of your child/dependent, indicate your child/dependent's level. If you are completing this form for the Community Division, please indicate "community". Email*If you are completing this on behalf of your child/dependent, indicate your email address. If you are visiting the building for another reason than class, state here: Do you exhibit any known symptoms of COVID-19, including fever or chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headaches, new loss of smell or taste, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?* Yes No Have you been in close physical contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19?*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection). Yes No Have you been directed by a local health authority or medical doctor to self-isolate or self-quarantine?* Yes No HiddenHave you traveled outside of the US or to a state designated as high risk by the PA Department of Health in the past 14 days? For more information, please visit https://www.health.pa.gov/topics/disease/coronavirus/Pages/Travelers.aspx Yes No Do you have a body temperature equal to or exceeding 100.4 degrees F?* Yes No Name of Person Completing This Form*If you completed this on behalf of your child/dependent, indicate your name. First Last Consent* By clicking this box you acknowledge that the above answers are correct.Today's date:* MM slash DD slash YYYY CAPTCHA Δ
