2020-2021 BGMS Check In Sheet COVID Screening/ Formularia de registro COVID de BGMS

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Please complete this form prior to entering BGMS/ Por favor llene este formulario antes de entrar a la escuela BGMS

Email *

First Name/ Primer Nombre *

Today's Date *

YYYY

Time *

Time

Room or space that you will report to or be in when on campus/ Marque a donde se reportara o estara en el plantel *

Main Office (Whole Building) / Oficina (todo el edificio)

Custodial/ Conserje

Room/ Salon 1

Room/ Salon 2

Room/ Salon 3

Room/ Salon 4

Room/ Salon 5

Room/ Salon 6

Room/ Salon 7

Room/ Salon 8

Room/ Salon 10

Room/ Salon 11

Room/ Salon 12

Room/ Salon 13

Room/ Salon 25

Room/ Salon 26

Room/ Salon 27

Room/ Salon 20

Room/ Salon Gym

Cafeteria

Room/ Salon 14

Mat Room (includes PE office)

Gymnasium

Room 4a

Room/ Salon 19

Other:

Required

I affirm that I have been without fever (100.4 or above) for 24 hours without the use of fever-reducing medication. Also that I have not had symptoms of respiratory illness (cough, shortness of breath, or runny nose), unusual muscle or body aches, fatigue, new loss of taste or smell, or gastrointestinal symptoms in the past 24 hours/ Yo afirmo que en las ultimas 24 horas no he tenido fiebre de mas (100.4 o mas alta) Tampoco he tomado medicamentos para reducir la fiebre. Tambien no he tenido sintomas de enfermedad respiratoria (tos, dificultad de respirar, nariz suelta),dolores musculares o corporales inusuales, fatiga, nueva pérdida del gusto u olfato o síntomas gastrointestinales en las últimas 24 horas. *

Yes/Si

I affirm that anyone I live with or anyone that I have been in close contact with have been without fever (100.4 or above) for 24 hours, without the use of fever-reducing medication, and that they have not had symptoms of respiratory illness (cough,shortness of breath, or runny nose) in the past 24 hours/ Yo afirmo que ninguna de las personas con las que vivo o tengo contacto cercano ha tenido fiebre de (100.4 o mas) en las ultimas 24 horas, sin el uso de medicamento para reducir la fiebre, y no han tenido sintomas de enfermedad respiratoria (tos, dificultad para respirar o nariz suelta) en las ultimas 24 horas. *

Yes/Si

I affirm that I have not been served with an order of isolation or quarantine within the past 2 weeks. Afirmo que no me han entregado una orden de aislamiento o cuarentena en las últimas 2 semanas.

Yes

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Your Position/Su Posición *

Cell Phone Number

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