Gogebic-Ontonagon ISD COVID-19 Employee Health Screening Form

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GOISD Employees are to complete this form daily before reporting to work. If you answer YES to any of the symptoms listed in Section 1 or YES to two or more symptoms listed in Section 2 or your temperature is 100.4 F or higher, do not report to work. Contact your supervisor, self-isolate at home and contact your primary care provider's office.

Name *

Section 1: Temperature *

Section 1: In the past two weeks, have you been tested for COVID-19? *

Yes

Section 1: In the past two weeks, have you had contact with someone diagnosed with COVID-19? *

Yes

Section 1: Have you been directed or told by the local health department or your health care provider to self-isolate or self-quarantine? *

Yes

Section 1: In the last 14 days, have you developed any of the following symptoms that are new / different / worse from baseline of any chronic illness? Check the box if the answer is yes. *

Subjective Fever (felt feverish)

New or worsening cough

Shortness of breath or difficulty breathing

I have no symptoms

Required

Section 2: In the last 14 days, have you developed any of the following symptoms that are new / different / worse from baseline of any chronic illness? Check the box if the answer is yes. *

Chills

Headache

Sore throat

Loss of smell or taste

Nausea

Vomiting

Diarrhea

I not experienced any of these symptoms.

Required

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