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C0VID-19 Screening Form-Cluster 5
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* Indicates required question
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Option 1
Enter your first name.
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Your answer
Enter your last name.
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Your answer
Do you have a temperature of 100.0 degrees Fahrenheit or higher when taken by mouth?
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Yes
No
Do you have a sore throat?
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Yes
No
Do you have a new uncontrolled cough that causes difficulty breathing (or, for an employee or student with a chronic allergy/asthmatic cough, a change in your cough from your normal baseline)?
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Yes
No
Do you have Diarrhea, vomiting, or abdominal pain?
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Yes
No
Do you have a new onset of severe headache, especially with fever?
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Yes
No
Within the last 14 days, have you or anyone in your family been exposed to someone with COVID-19 positive test results?
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Yes
No
I understand that, if I answer yes to any one of the above questions, I am to report to my supervisor and school nurse.
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Yes
No
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