ESC Region 12 Participants Daily Self Screening
Individuals entering ESC Region 12 buildings for any reason are asked to complete this form (only once per day) prior to entering any ESC building for any reason.  Entry will not be allowed until this form is complete.
In order to protect our staff as well as our customers, we have instituted protocols to screen employees and participants alike.  Your temperature will be taken by a digital facial temperature scanner.  Anyone with a temperature at or above 100.4° F will be asked to sit in a specified location for 10 minutes and then a digital infrared thermometer will be used for a second temperature reading.  Should the temperature still be at or above 100.4° F then the individual will be asked to leave the premises.
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Email *
Name *
School District *
𝐓𝐨𝐝𝐚𝐲'𝐬 𝐃𝐚𝐭𝐞 (𝐍𝐨𝐭 𝐲𝐨𝐮𝐫 𝐛𝐢𝐫𝐭𝐡𝐝𝐚𝐲) *
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I have checked my temperature in the last 24 hours and I did NOT have a temperature at or above 100.4° F. *
Required
Please check if you or anyone in your household have any or all of the symptoms below: (selection of one or more of these symptoms may require you to work remotely until this or these symptoms have subsided).  
To the best of my knowledge, I have not been in close contact with someone who has been diagnosed with COVID-19 or has been asked to self-quarantine by the state of local health officials. *
The purpose of my visit today is ...
If you chose other above please explain here
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