Mandatory WISD Student Facility Access Health Screening Form

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Please answer the following before entering any WISD facility.

If the answer is yes to any of the symptoms below, your access to WISD facilities is prohibited. Thank you for your understanding and cooperation during the COVID-19 pandemic.

Date *

YYYY

Last name *

First name *

Are you experiencing any of the following sign/symptoms of COVID-19? *

Yes

Cough

Shortness of breath

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

Loss of taste or smell

Diarrhea

Feeling feverish or a temperature of 100 degrees or greater

Known close contact with an individual that has a lab tested case of COVID-19 ( being directly exposed to infectious secretions (e.g., being coughed on); or being within 6 feet for a cumulative duration of 15 minutes

Temperature Check

Facility Return Criteria

If the answer to any of the above is yes, please do not visit a district facility until the following criteria are met:

1. At least 3 days (72 hours) have passed since recovery (resolution of fever without the use of fever-reducing medications)

2. Improvement in respiratory symptoms (e.g., cough, shortness of breath) has occurred.

3. At least 10 days have passed since symptoms first appeared.

I certify that to the best of my knowledge, my responses to the above questions are true. *

Yes

Required

Electronic Signature *

Submit

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