JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Covid 19 Screening
In accordance with Wayne County Health Officer and Local Health Emergency Order #20-02, all employees working or volunteering on-site must complete a health screening prior to reporting. A new screening must be completed each time an employee or volunteer reports to a school site.
This order will remain in effect until it is determined by the Health Officer of Wayne County Local Health Department. that the threat to the public's health and lives is no longer present.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Date reporting
*
MM
/
DD
/
YYYY
The building you are reporting to
*
Choose
Carlson
Shumate
Chapman
Hunter
Parsons
Weiss
Transpotation
Stark
Rockwood
Please type your email address
Your answer
Have you been diagnosed with COVID-19 in the last 14 days
*
Yes
No
Have you had close contact with anyone diagnosed with COVID-19 in the last 14 days?
*
Yes
No
Are you experiencing any of the following symptoms: fever, cough, shortness of breath, sore throat or diarrhea?
*
Yes
No
Do you have a fever of 100.4 degrees Fahrenheit or above?
*
Yes
No
You will receive an email shortly if you are permitted on Gibraltar School District property today.
Thank you
Clear selection
CONFIRMATION: By typing your name below, you agree that the information you provided is current and accurate.
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Gibraltar Schools.
Report Abuse
Forms
