STAFF DAILY HEALTH SCREENING
For COVID-19
Employee's Name
*
First Name
Last Name
Have you had close contact (within 6 feet, for 15 minutes) in the last 14 days with someone diagnosed COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?
*
YES
NO
Do YOU have any of the following symptoms?
*
Rows
YES
NO
FEVER
1
2
CHILLS
3
4
DIFFICULTY BREATHING
5
6
NEW COUGH
7
8
NEW LOSS of TASTE or SMELL
9
10
Since you were last at school, have YOU been diagnosed with COVID-19?
*
YES
NO
I have read and understand Frankie Lemmon School's COVID-19 Policies and Procedures:
*
Initial Here
I acknowledge that the information I have given is accurate and complete.
Today's Date
*
Employee Signature
*
Submit
Should be Empty: