ESMS- 8118 Visitor Covid-19 Screening Form

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Visitors must fill out the screening form .
If you marked yes to 1 or more of the COVID questions below, DO NOT physically enter schools or facilities at this time.
You need to stay home and follow instructions from the LA County Department of Public Health, as set forth in the following link:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html

Email *

First Name *

Last Name *

Date *

YYYY

Time In *

Time

Time out *

Time

Do you have a cough?

Yes

Clear selection

Are you experiencing shortness of breath?

Yes

Clear selection

Are you experiencing fever or chills?

Yes

Clear selection

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)?

Yes

Clear selection

Have you had close contact with, or cared for someone diagnosed with COVID-19 within the last 14 days?

Yes

Clear selection

Are you currently required to be under isolation or quarantine?

Yes

Clear selection

Send me a copy of my responses.

Submit

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