Loading...

BREUIL FUSSION ACADEMY,CORP 

13501 NW 107 AVE,HIALEAH GARDENS,FL,33018.

 

 

 

 

BFA COVID-19 Screening

The safety of our staff, students, families and visitors remain BFA’s overriding priority. As the coronavirus disease (COVID-19) outbreak continues to evolve and spreads globally, Breuil Fussion Academy are monitoring the situation closely and will periodically update company guidance based on current recommendations from the Centers for Disease Control and Prevention and the World Health Organization. Only business critical visitors are permitted at any BFA facility at this time. 

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our staff, students and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time. 

 

 

 

First VISITOR Name

First Name*

Middle Name

Last Name*
First VISITOR Date of Birth*
First VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


First VISITOR Signature*
Second VISITOR Name

First Name*

Middle Name

Last Name*
Second VISITOR Date of Birth*
Second VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Third VISITOR Name

First Name*

Middle Name

Last Name*
Third VISITOR Date of Birth*
Third VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Fourth VISITOR Name

First Name*

Middle Name

Last Name*
Fourth VISITOR Date of Birth*
Fourth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Fifth VISITOR Name

First Name*

Middle Name

Last Name*
Fifth VISITOR Date of Birth*
Fifth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Sixth VISITOR Name

First Name*

Middle Name

Last Name*
Sixth VISITOR Date of Birth*
Sixth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Seventh VISITOR Name

First Name*

Middle Name

Last Name*
Seventh VISITOR Date of Birth*
Seventh VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Eighth VISITOR Name

First Name*

Middle Name

Last Name*
Eighth VISITOR Date of Birth*
Eighth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Ninth VISITOR Name

First Name*

Middle Name

Last Name*
Ninth VISITOR Date of Birth*
Ninth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Tenth VISITOR Name

First Name*

Middle Name

Last Name*
Tenth VISITOR Date of Birth*
Tenth VISITOR Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Screening
1-Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
No
Yes
2-Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*
No
Yes
3-Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 AND "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW. YOUR ACCESS TO CDC FACILITIES IS APPROVED.*
No
Yes
4. 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).*
No
Yes
5. Are you currently waiting on the results of a COVID-19 test? IMPORTANT: ANSWER "NO" IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST*
No
Yes

If the answer is "yes" to any of the questions, access to the facility will be denied.


Note: if you plan to be onsite for consecutive days, please immediately advise your BFA host if any of your responses change. The information collected on this form will be used to determine your access right to BFA facilities. Any questions should be directed to breuilfussionacademy@live.com


Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!