Harbor Beach Community School

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This form must be filled out daily by all school employees before they have contact with any students, and you must do all you can to avoid contact with other employees until this form is completed.

The safety of our students and employees is our overriding priority. As the Coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the Coronavirus and reduce the potential risk of exposure to our workforce, we are requiring everyone to complete and submit this questionnaire prior to work each day. Staff members must not become actively involved on any part of HBCS campus or HBCS related events off campus until after responding to this questionnaire.

If you answer yes to any indicators, you MUST report to your immediate supervisor, Dr. Bishop, or one of the secretaries. Additionally, we ask that you attempt to contact Mr. Kowaleski.

Please respond to each of the following questions truthfully and to the best of your ability. Your
participation is important to help us take precautionary measures to protect you, our other employees, and most of all, our students!

Name of Employee *

Today's Date *

YYYY

Please select who receives your form upon completion:

Lindsay Holdwick (Elementary Staff, Middle School Staff, Building Principal, OT, PT, Speech Language, HISD employees)

Tracy Tamlyn (High School Staff, Food Service, Custodial, Admin Team, Athletics, DHHS, Health Center)

Clear selection

Have you received the COVID-19 Vaccine?

Yes 1 Dose

Yes 2 Doses (completed the vaccine treatment)

Clear selection

Are you currently experiencing or have you experienced in the last 24 hours any of the following symptoms? (Temperature must be taken within 1 hour of answering this survey question.) *

Yes

Fever (100.4 or greater)

Cough

Shortness of breath or difficulty breathing

Sore throat

New loss of taste or smell

Chills

Head or muscle aches

Nausea, diarrhea, or vomiting

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

Yes

Have you been tested for COVID-19 and are waiting to receive test results? *

Yes

Have you tested positive for COVID-19, or are you pressumed positive for COVID-19 based on your health care provider's assessment or your symptoms? *

Yes

I have tested positive in the past but at the date I'm submitting this form do not a second time meet the above

In the past 14 days, have you been on a commercial flight or a cruise or traveled outside the United States? *

Yes

Is there any reason why you feel you are at high risk of contracting COVID-19? *

Yes

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