Daily Health Form (Revised 1/22/21)

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Any of the symptoms below could indicate a COVID-19 infection and may put you at risk for spreading illness to others. Please note that this list does not include all possible symptoms and that someone with COVID-19 may experience any, all or none of these symptoms. Please check yourself daily for these symptoms:

Full Name *

Staff

Visitor

Student Teacher

Substitute Teacher

Required

Have you received a COVID 19 Vaccine in the last 48 hours?

Yes

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Section 1: Symptoms - Column A: If **FEVER or **VOMITING or **DIARRHEA is checked and no other field is checked, please stay home and notify the school nurse. If TWO OR MORE of the fields in Column A are checked off please stay home, notify your supervisor and school nurse.

**Fever (100 degrees or higher)

**Diarrhea

Nausea or **Vomiting

Chills

Congestion or runny nose

Fatigue

Headache

Muscle aches (myalgia)

Shivers (rigors)

Sore throat

Column B If ONE field in Column B is checked off, please stay home, notify your supervisor and school nurse.

Cough

Difficulty breathing

New loss of smell

New loss of taste

Shortness of breath

Section 2: Close Contact/Potential Exposure. If any of the fields in section 2 are checked off, you should remain home for 14 days from the last date of exposure or date of return to New Jersey. Contact you provider or local health department for further guidance. Please verify if in the last 14 days:

You had close contact (within 6 feet of an infected person for 15 minutes or more minutes during a 24 hour period) with a person with COVID-19

Someone in your household is diagnosed with COVID-19 or being tested for COVID-19

You have traveled from any U.S. state or territory outside of New York, Connecticut, Pennsylvania, and Delaware.

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