EMS/ELA STAFF Health Screening Form

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***This form must be completed prior to entering any Englewood Schools program or building***

If any of the MAJOR symptoms below are reported:
1. Send person home immediately.
2. Increase cleaning in your facility and ensure staff & students are wearing masks and maintain a 6 foot distance from one another at all times.
3. Exclude person until they are fever-free (without medication) for 72 hours and 10 days have passed since their first symptom unless they present a documented alternative diagnosis from a medical provider.
4. If multiple students/staff have symptoms, contact your RN

Name (Last, First) *

Have you experienced any of the following symptoms in the past 24 hours? *if you answer yes to any of these, PLEASE STAY HOME and contact your direct supervisor* *

FEVER >100.4° F AND/OR CHILLS

COUGH

NEW LOSS OF TASTE OF SMELL

VOMITING

SHORTNESS OF BREATH/DIFFICULTY BREATHING

none of the above

Required

Please verify any additional symptoms *if you answer yes to any of these, please complete secondary screening & temperature re-check* *

fatigue

muscle or body aches

headache

sore throat or runny/stuffy nose

pink eye / conjunctivitis

nausea or diarrhea

none of the above

Required

Have you been in close/direct contact with anyone experiencing COVID-19 symptoms, or anyone who has tested COVID positive within the past 48 hours? *

Yes - STAY HOME AND CONTACT YOUR SUPERVISOR

Temperature at time of screening: *

Below 99.5° F

99.6° - 100.3° F (secondary screening required/re-check temp at 12:00PM)

ABOVE 100.4° F (SEND HOME)

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