Teacher/Participating Adult/Visitor Health Screening

Question Title

* 1. Date

Date

Date

Question Title

* 2. Name

Question Title

* 3. Position/Purpose

Teacher

Participating Adult—5-day PreK

Participating Adult—3-day PreK

Participating Adult—3-YR-Old Class

Substitute

Visitor

Question Title

* 4. Have you had a fever within the past 72 hours?

Yes

No

Question Title

* 5. Have you experienced any of the following symptoms within the past 24 hours that is not typical?

Congestion or runny nose
Cough
Sore throat
Nausea or vomiting
Diarrhea
Muscle or body aches
Difficulty breathing/shortness of breath
Loss of taste or smell

Yes

No

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* 6. Have you tested positive for COVID-19 within the last 14 days?

Yes

No

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* 7. Have you had known close or proximate contact with anyone who has tested positive for COVID-19 in the last 14 days?

Yes

No

Question Title

* 8. IF you answered YES to any of the above questions, you may not enter the school building today and you must confirm your acknowledgment by typing your initials in the box below. Please contact the school immediately with more information.