I & O Staff Health Screening Form -- Forma de examen Salud para  los empleados
Staff
Thank you for helping 27J Schools stay healthy.  You should fill out this form only if you have signs/symptoms of illness, have received a COVID19 test and are awaiting results, or have tested positive for COVID.  Each form is school specific.  Please stay home until you have heard from your school via email or phone call. --
Empleados
Gracias por ayudar a las Escuelas 27J a mantenerse saludable.  Usted debe llenar este formulario sólo si tiene signos/síntomas de enfermedad, ha recibido una prueba COVID19 y está esperando resultados, o ha tenido una prueba COVID19 positiva.  Cada formulario es específico para cada escuela.  Por favor, quédese en casa hasta que su escuela se comunique con usted por correo electrónico o por teléfono.

登入 Google 即可儲存進度。瞭解詳情
Staff Name (Last, First) Nombre del empleado (apellido, Nombre) *
Staff Date of Birth -- Fecha de nacimiento del empleado *
MM
/
DD
/
YYYY
Staff  Phone Number -- Número de teléfono del empleado *
Staff Email *
Building Name -- Nombre de la instalación *
必填
Staff Grade Level -- Nivel de grado en el que trabaja el empleado *
必填
Cohort or Community *
Do you sponsor, coach, supervise, or otherwise participate in any additional 27J cohorts than the one you named above (sports teams, school clubs, lunch duty, etc)? Please list or write NA. *
If you have household members at different school(s) or 27J building(s), please select which site(s). -- Si usted tiene miembros de la familia que asisten a una escuela(s) diferentes o  las instalaciones del 27J, por favor seleccione el lugar(es) *
必填
Are you currently experiencing any symptoms? *
If you answered that you are experiencing symptoms, when did they begin?
MM
/
DD
/
YYYY
If experiencing symptoms, what time did symptoms begin on that date? (Choose 8:00 AM if unsure or if you woke up with symptoms)
時間
:
Please check which symptoms you are having -- marque los síntomas que esta teniendo *
必填
COVID Vaccine Status
清除選取的項目
Have you had a known exposure to someone positive for COVID 19 in the last 14 days? *
If you answered that you have had a known exposure in the last 14 days to someone positive for COVID-19, on what date did contact last occur?
MM
/
DD
/
YYYY
Have you recently been tested for COVID? If yes, which type? (To qualify for COVID Leave, 27J staff must seek a proctored COVID test) *
If yes, when was the COVID test sample collected?
MM
/
DD
/
YYYY
If you were tested for COVID recently, what were the results?  (If you have received COVID test results, please forward them to sstsaveur@sd27j.net)
清除選取的項目
When were you last on site? (For in person work, meetings, 27J sports or activities, etc) *
MM
/
DD
/
YYYY
If relevant, please add any additional details you feel would be helpful to determine your return to work date.
提交
清除表單
請勿利用 Google 表單送出密碼。
這份表單是在 School District 27J 中建立。 檢舉濫用情形
Google 表單