Coronavirus Disease 2019 (COVID-19) Screening Form- Screening Criteria for ALL Staff

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To be completed by an EISD employee prior to physically working at a district facility during the Emergency School Closing related to COVID-19. HIPPA Laws apply.

First Name Last Name *

Affiliation *

Employees

Other

Have you traveled to China, Hong Kong, Iran, Japan, South Korea, Europe, United Kingdom, Ireland, Italy, Spain, France, or any other areas with on-going community spread of COVID-19 OR has a close contact (approx. 6ft) with a person known to have COVID-19 or Person under investigation for COVID-19 within the last 14 days of symptom onset? *

Yes

Do you have any of the following symptoms: Fever or signs and symptoms of lower respiratory illness (cough or shortness of breath) *

Yes

I attest the answers provided above are true and correct to the best of my knowledge. *

Yes

I attest to report to my supervisor and changes in my health status after submitting this form. *

Yes

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