HEALTH SELF-SCREENING

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The safety and health of employees is best achieved through personal responsibility for your actions. The following questions must be answered each day that you report to work at a district facility.

Email *

Today's Date *

YYYY

Name *

Employees: Site/Department employed at / Visitor: Site or Department you are visiting today. *

Are you experiencing any of the following as NEW, 𝙐𝙉𝙀𝙓𝙋𝙇𝘼𝙄𝙉𝘼𝘽𝙇𝙀 symptoms?

If you have any of the following, DO NO REPORT PHYSICALLY TO WORK AND NOTIFY YOUR SUPERVISOR:

Fever (>100.0) *

Yes

Cough? *

Yes

Shortness of breath or difficulty breathing *

Yes

Chills? *

Yes

Repeated shaking with chills? *

Yes

Muscle pain? *

Yes

Headache? *

Yes

Sore throat? *

Yes

New loss of taste or smell? *

Yes

Diarrhea? *

Yes

Nausea or vomiting? *

Yes

Congestion or runny nose? *

Yes

Fatigue? *

Yes

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Mountain Empire Unified School District. Report Abuse

Forms