Covid-19 Self-Health Assessment

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Please fill this survey out before entering a CCISD building.

IF AN EMPLOYEE OR VISITOR ANSWERS YES TO ANY OF THE FOLLOWING QUESTIONS, YOU MAY NOT ENTER A CCISD FACILITY AND ARE ENCOURAGED TO CONTACT YOUR PHYSICIAN.
THANK YOU FOR DOING YOUR PART TO KEEP CCISD SAFE.

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Name *

Have you or anyone in the home had a fever or felt feverish (chills or shaking) in the past 3 days? *

Yes

Have you taken any fever-reducing medication such as Tylenol or Ibuprofen in the past 24 hours for reasons related to illness or fever? *

Yes

Have you or anyone in the home shown signs of respiratory illness (cough, shortness of breath, sore throat, loss of sense of taste or smell) in the past 10 days? *

Yes

Have you or anyone in the home shown signs of gastrointestinal illness (recurrent nausea, vomiting, diarrhea) in the past 10 days? *

Yes

Have you or anyone in the home had new or worsening headaches or muscle pains in the past 10 days (excluding migraines or injuries)? *

Yes

Have you or anyone in the home had any contact with someone with a confirmed diagnosis of COVID-19 in the past 14 days? *

Yes

Are you or anyone in the home under investigation or monitoring for suspected COVID-19? *

Yes

Please type name below confirming the following- I understand that I must self-assess before coming to a CCISD facility. *

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