GTCYS Staff Health Screening Form

Name*

First Last

Has a member of your household been tested and diagnosed with a case of COVID-19 within the past 5 days?*

If yes, please stay home, monitor for symptoms, and strongly consider taking a rapid antigen before visiting GTCYS’ office.

Yes
No

In the last 48 hours, have you had any of the following NEW symptoms? If yes or you have to think twice about whether your symptom(s) might qualify, you should work from home. We strongly encourage anyone with symptoms to get a negative COVID-19 test before visiting GTCYS’ office.*

--Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating
--Cough
--Runny Nose
--Congestion
--Fatigue
--Trouble breathing, shortness of breath or severe wheezing
--Chills or repeated shaking with chills
--Muscle aches
--Sore throat
--Loss of smell or taste, or a change in taste
--Nausea, vomiting or diarrhea
--Headache

Yes
No

I verify that my responses are truthful, and that I am able to go into the office.*

Click here to verify

If you answered yes to any of the above questions, you may not go into GTCYS’ office or attend any in-person activities. Please stay home.*

I understand

Greater Twin Cities Youth Symphonies Mark Russell Smith, Artistic Director

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