DAILY COVID-19 HEALTH SCREENING FORM

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Do not come to school if you:

Have a temperature of 100.4◦ F or higher,
Have been exposed within the past 14 days to someone diagnosed with COVID-19,
Have been exposed within the past 14 days to someone with symptoms of COVID-19,
Have symptoms of COVID-19.

Last Name *

First Name *

Do you have any symptomology matching TWO OR MORE of the fields in Column A or AT LEAST ONE field ib Column B? Yes of No

Have you recently been in close contact with anyone who has exhibited any symptoms?

Yes or No

Have you recently been in contact with anyone who has tested positive for COVID-19?

Yes or No

Have you traveled outside of New Jersey or the United States within the past 14 days? Please check the website below to see if a region you visited requires a 14-day quarantine period.

https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey

Yes or No

If you answered “yes” to any question above or if you have a fever of 100.4 degrees or higher, you are not cleared to work/enter the building until you discuss symptomology with a health care professional and contact the principal or direct supervisor. If you have been in a state that requires a 14-day quarantine, you are not cleared to enter the building. Please contact the principal or direct supervisor.

I am cleared to work in-person/enter the building today. *

Yes

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