FIAO Health Screening Questionnaire

FIAO Health Screening Form for entering Il Centro Facility

At FIAO, the health and safety of our Members and Staff remains our top priority. We continue to closely monitor guidance from the CDC along with the federal, state, and local directives. Our approach to the situation continues to be with an abundance of caution to ensure the safety of all. We ask for your support in the shared responsibility to minimize the risk of exposure and to protect our individual and collective health. To that end, all Staff and Visitors to our office, school sites and center need to complete the short Questionnaire below. For everyone whose response on any of these questions is YES than as a precautionary measure, she/he will be UNABLE to continue with their visit to FIAO and the staff or visitor will be asked to please make alternative arrangements with FIAO. The visitor’s answer below needs to be verified, signed off with a date and retained at the site in an accessible file for future reference if needed. Thank you for your understanding and cooperation. (Questions with an* are mandatory)

Do you have any reason to believe you may have, or may have been exposed to, COVID-19 in the past 14 days?*
- YES
- NO
Are you currently experiencing flu-like symptoms, including cough, fever, difficulty breathing/shortness of breath?*
- YES
- NO
Have you or anyone in your immediate household, been in close contact with anyone confirmed or presumed positive for COVID-19 in the past 14 days?*
- YES
- NO
Did you, or anyone in your immediate household, travel internationally or travel on a cruise ship in the past 14 days?*
- YES
- NO
Email
Phone Number*
DIGITAL SIGNATURE OF MEMBER/VISITOR:*
(PLEASE TYPE NAME)
First Last