Lyonsgate Staff Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form must be completed every day, after 5:00 a.m. and before you arrives for work. If this online form is not completed you are required to answer all screening questions in person when you arrive.

First Name: *

Last Name: *

Are you, or anyone in your household, currently experiencing any of these symptoms? *

Choose the main symptom that is new, worsening, and not related to other known causes or conditions you already have. If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “None of the above.”

Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher).

Cough or barking cough (croup). Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have).

Shortness of breath. Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have).

Decrease or loss of taste or smell. Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.

Sore throat. Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.

Difficulty swallowing. Painful swallowing (not related to other known causes or conditions you already have).

Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.

Pink eye. Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have).

Headache. Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “None of the above."

Digestive issues like nausea/vomiting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.

Muscle aches. Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “None of the above.”

Extreme tiredness. Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “None of the above.”

Falling down often. For older people.

None of the above.

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lyonsgate Montessori School. Report Abuse

Forms