Notre Dame Academy – COVID-19 Self Test Self Test First Name * Last Name * Email * Student ID (if not a student, enter phone number) # Have you been tested and tested positive for the virus that causes COVID-19 in the last 14 days? * Yes No Do you have a temperature of 100.4 or greater, as measured by a reliable and accurate home thermometer? * Yes No Do you have any COVID-19 related symptoms, including persistent non-allergy related cough, shortness of breath, difficulty breathing, headache, chills, muscle pain not attributable to recent activity, sore throat, new rash, GI symptoms (i.e., vomiting or diarrhea), or new loss of taste or smell? * Yes No Has anyone in your household been diagnosed with, or showing symptoms of, COVID-19 in the last 14 days? * Yes No Have you been in close contact with someone diagnosed with COVID-19 or who has tested positive for the virus that causes COVID-19 in the last 14 days? * Yes No Have you traveled outside of the United States or to a state with a positivity rate of 15% or higher in the last 14 days or been in close contact with someone who has traveled outside of the United States or to a state with a positivity rate of 15% or higher in the last 14 days? Have you traveled, in the last 14 days, via public transportation such as a plane or bus? * Yes. Enter StateYes. Enter State No Submit If you are human, leave this field blank.
