Self Assessment Form

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Every person entering the building MUST complete this form prior to coming in.

Email *

Last Name, First name: *

1. Have you or anyone in your household, had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100.4 degrees Fahrenheit? *

Yes

2. Have you or anyone in your household tested positive for COVID-19 or are awaiting test results within the last 14 days? *

Yes

3. Have you or anyone in your household come in contact with any individual who is in quarantine, isolation, or has tested positive for COVID-19 in the last 14 days? *

Yes

4. Have you or anyone in your household come in contact with any individual who has the COVID-19 signs and symptoms listed in Question 1 above in the last 14 days? *

Yes

5. In the past 14 days have you or anyone in your household traveled to NJ from a State and/or Country which requires you to self-quarantine for 14 days? (as per Governor Murphy’s guidelines) *

Yes

I agree to immediately let the District know if any of the information on this form changes by notifying the School Principal *

Agree

Today's Date: *

YYYY

If you answer yes to any of the questions above, please contact Yolanda Gomez, Director of Human Resources immediately at 732-376-6200 ext: 30-152 *

I acknowledge the above statement

Required

Send me a copy of my responses.

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