ECS Support STAFF and SUBSTITUTES - COVID-19 Health Screening

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This form is being used for support staff and substitutes at the school building during hybrid learning. General staff should complete their form through PowerSchool PowerTeacher Login. Parents/Guardians of students should complete their from through PowerSchool Parent login.

Anytime you have questions or concerns regarding this screening, please don't hesitate to contact the Nurse's Office.

Name (STAFF only please.) *

Contact Number *

1. Do you have a temperature over 100.4°F? *

Yes

2. In the last 10 days, have you tested positive for COVID-19, or are you being tested of COVID-19 due to illness. *

Yes

3. In the last 10 days, have you experienced COVID-19 like ILLNESS as defined by ANY of the following symptoms? (1) Cough, (2) Shortness of Breath, (3) Difficulty Breathing, (4) New Loss of Smell, (5) New Loss of Taste. *

Yes

4. In the last 10 days, have you experienced COVID-19 like ILLNESS as defined by TWO OR MORE of the following symptoms? (1) Fever - measured or subjective, (2) Chills, (3) Rigors- shivers, (4) Myalgia - muscle aches, (5) Headache, (6) Sore Throat, (7) Nausea or Vomiting, (8) Diarrhea, (9) Fatigue, (10) Congestion or runny nose. *

Yes

5. In the last 14 days, have you been in CLOSE CONTACT with a POSITIVE OR POSSIBLE case of COVID-19? *

A CLOSE CONTACT is defined as being within 6 feet for 15 minutes or more, cumulative over 24 hours. A POSSIBLE CASE is defined as an Individual with COVID-19 Illness Symptoms (see above), or being tested for COVID-19 due to illness.

Yes

6. In the last 10 days, have you traveled internationally, or beyond the 50 US states? *

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

By submitting this form, you are agreeing that (1) your answers are valid and true, (2) if any of your answers are "Yes" (or change to "Yes" after submission), you will not enter the ESC building (contact ECS for instructions), and (3) if you develops any signs and symptoms of illness in the three days following your attendance, you will notify ECS. *

I Agree.

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