RCSD Wellness Screening Form

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Please complete this before entering our campus/building to note if you are in a healthy condition. If you answer no to any of these questions, please reschedule your visit.

Email address

Last Name *

First Name *

Cell Phone Number *

Location *

Reason for Visit

Please answer the following questions. If you do not affirm, please reschedule your visit and alert your district contact. *

Yes I affirm.

No, I do not affirm.

I affirm that I have not received a positive COVID-19 test in the last ten days.

I affirm that, in the last 24 hours, I have not had a fever (100.4 or above), without the use of fever-reducing medications.

I affirm that in the last 24 hours, I have not had symptoms of respiratory illness (cough, shortness of breath, or runny nose).

I affirm that, to my knowledge, I have not had loss of taste or smell, loss of appetite, or diarrhea

I affirm that, to my knowledge, nobody in my household or with whom I have been in close contact has received a positive COVID-19 test in the last ten days.

I affirm that, to my knowledge, nobody in my household or with whom I have been in close contact has had a fever (100.4 or above), without the use of fever-reducing medications.

I affirm that, to my knowledge, nobody in my household or with whom I have been in close contact has had symptoms of respiratory illness (cough, shortness of breath, or runny nose).

I affirm that, to my knowledge, nobody in my household has had loss of taste or smell, loss of appetite, or diarrhea.