Building Entrance Form Screening Checklist for Students, Parents, Visitors, & Staff Screening Checklist for Students, Parents, Visitors, & Staff Please complete this form for each visitor entering the building. Date of Entry * First Name * The person entering the building. Last Name * The person entering the building. Temperature * Have you been exposed to anyone with COVID-19? If yes, you are restricted from entering the building. * No Yes Does the individual have any of the following symptoms? (Check all that apply.) * No symptons Cough Shortness of Breath Fever Repeated shaking with chills Severe Headache New loss of taste or smell Diarrhea Muscle Pain Soar throat Vomiting Other illness Washing hands for at least 20 seconds is required upon entry and before exiting the building. * Yes, I understand and agree. It is best to use the restroom before arriving, however if you need to please ask permission first. * Yes, I understand and agree. Do not touch anything or anything unless it is your own instrument, music, or pencil, or other equipment. Pianos and other facility equipment that has been touched will be wiped down after each use use by the teacher after the student has exited the room. Doors will be opened and closed by LSM staff and teachers. * Yes, I understand and agree. Adult Signature * Clear Submit