COVID-19 Screening for Preschool Building

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

(based on CDC guidance from as of 9/14/20 and Illinois SBE as of 10/23/20, updated April 2021)
This screening tool is one of several measures UABC is taking to ensure a healthy setting for our students, employees, guests, and their families. Vaccinated & asymptomatic *employees* are only required to enter their name. Thank you for completing this questionnaire out of consideration for the well-being of others.

Name *

Which of the following symptoms have you experienced in the past 2 weeks OR since your last screening for this building?

Fever > 100.4

New headache that is moderate or severe

Shortness of breath or difficulty breathing

New/worsening cough or sore throat (different than your seasonal allergies)

Vomiting, diarrhea, or nausea

Muscle/body aches or abdominal pain

New congestion or runny nose

New loss of smell or taste

Fatigue from unknown cause

None of the above

Have you been diagnosed with COVID-19, OR are you waiting for COVID-19 test results?

Yes

Clear selection

Have you been in close contact with someone who has tested positive for COVID-19, who is waiting for COVID-19 test results, or who is exhibiting COVID-19-like symptoms?

Yes

Maybe

Clear selection

If you answered YES or MAYBE to any of the above questions, please explain.

What was your most recent temperature reading? And, when was it taken? (If you do not have a thermometer, someone can take your temperature at the building's entrance.)

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms