Almont School District Employee COVID -19 Screening Questionnaire
The safety of our staff and students is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our staff and students, we are asking everyone to complete and submit this questionnaire prior to entering the worksite.
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Last Name *
First Name *
Due to the recent increase in district quarantine cases, we would like to know if you have been fully vaccinated? *
What building do you work in? *
Are you currently experiencing, or have you experienced in the past 10 days, any of the following symptoms? *
Yes
No
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Cough
Shortness of breath or difficulty breathing
Sore throat
New loss of taste or smell
Chills
Head or muscle aches
Nausea, diarrhea, vomiting
In the past 10 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
Required
In the past 10 days, have you been in close proximity to anyone who has tested positive for Covid-19? *
Required
Have you been tested for COVID-19 and are waiting to receive test results? *
Required
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