JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Self Assessment
If a staff member OR student ANSWERS YES TO ANY OF THE FOLLOWING QUESTIONS, YOU MAY NOT ENTER the school FACILITY AND ARE ENCOURAGED TO CONTACT YOUR PHYSICIAN.
THANK YOU FOR DOING YOUR PART TO KEEP our schools SAFE.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Hey What is your name?
*
Your answer
What section are you in?
*
Flute
Clarinet
Alto Sax
Low Reed
Trumpet
Mellophone
Low Brass
Drumline
Pit
Color Guard
Staff
1.
Have you or anyone in the home had a fever or felt feverish (chills or shaking) in the past 3 days?
*
Yes
No
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
No
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
No
Have you or anyone in the home shown signs of gastrointestinal illness (recurrent nausea, vomiting, diarrhea) in the past 10 days?
*
Yes
No
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
No
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
No
Are you or anyone in the home under investigation or monitoring for suspected COVID-19?
*
Yes
No
8.
*If you have traveled outside the state of Texas in the past 14 days, please adhere to the Texas Department of State Health Services travel advisories and quarantine instructions listed on the COVID-19 webpage of its website under Information for Travelers.
*
Yes (1): I have traveled but do not need to quarantine per the TDSHS instructions
Yes (2): I have traveled but I must quarantine per to the TDSHS instructions
No: I have not traveled and do not need to quarantine
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of CCISD.
Report Abuse
Forms