STAFF - COVID 19 Intake Questionnaire
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Last Name, First Name of STAFF: *
School Building Staff is affiliated with: *
Required
Please list siblings, friends and/or staff members your student has had contact with that are affiliated through Montevideo Public Schools:
Symptoms of Staff (check ALL that apply) *
Required
Date symptoms began:
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Have you been tested? *
If YES,  when was the test taken
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What were the test results?
Clear selection
Have you received a positive test result in the last 90 days? *
If you have received a positive COVID test in the last 90 days please provide the date of the Positive test:
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If positive, please provide us a list of students and staff that you would have come within 6ft of for a cumulative time of 15 min or more within 24 hrs.  This does not have to include everyone in your class, but more specifically those that fit into that close proximity.
When was your last date of attending work? *
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Are you a coach/organizer of a school related activity? *
If yes, what activity?
Have you been identified as a DIRECT CONTACT of a positive COVID case?
Clear selection
If yes, is the positive case a member of the same household?
Clear selection
If no, when was the last date of exposure with the positive case?
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If yes, is the positive household member able to isolate from others (ex: wearing a mask around others and in shared spaces indoors, staying in separate bedroom, using a separate bathroom or cleaning between uses, not using the same kitchen or cooking for others, limiting time in shared spaces with others)?
Clear selection
Date positive person began to isolate:
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Date positive persons symptoms began:
MM
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DD
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What is your preferred method of contact for a follow-up? *
Required
Please provide us with a NAME, PHONE NUMBER, and EMAIL you can best be reached below. Someone will be in touch with you within 24-48 hours.
Other questions, concerns and/or information that could help us with your case:
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