September NBC Employees Covid Questionnaire/Statement reporting to Mr. McKee.

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All employees are directed to complete this form each day. Responses to these questions will be automatically recorded and stored. These responses will only be available to your direct Supervisor, the Superintendent, his designees, and NBC's school physician.

Last Name *

First Name *

SECTION 1: Symptoms

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 people with COVID-19 may experience any, all, or none of these symptoms.

COLUMN A. Please select symptoms:

Fever (measured 100.4' or subjective)

Chills, Shivers

Muscle Aches

Headache

Sore Throat

Nausea, Vomiting, Diarrhea

Fatigue

Congestion or Runny Nose

COLUMN B. Please select symptoms:

Cough

Shortness of Breath

Difficulty Breathing

New Loss of Smell or Taste

People who are sick (e.g. fever, vomiting, diarrhea) should not attend school in-person.

If TWO OR MORE of the fields in Column A are checked off OR AT LEAST ONE field in Column B is checked off, please stay home and notify the school for further instructions.

SECTION 2: Close Contact/Potential Exposure.

Please select if:

You had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

You have traveled to an area of high community transmission. (NJ Travel Advisory List https://bit.ly/2DIALA0) If so, name the state below.

Other:

If ANY of the fields in SECTION 2 are selected, you should remain home for 14 days from the last date of close contact exposure or date of return to New Jersey.

Contact your provider or your local health department for further guidance.

Based on your responses to symptoms and exposure above, will you report to work today? If NO, please contact your supervisor for further information. *

By submitting this form I acknowledge that I have provided accurate information.

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