ONE-Time Staff COVID-19 Daily Self Checklist Sign-Off
Instructions:
Staff are required to screen themselves according to this checklist each day and take your own temperature before coming to work. By coming to work, you certify that you have honestly answered NO to all of the questions below.

If you have answers NO to all questions, you may come to work that day.

If you answer YES to any of the questions below, you must not come into work and notify either Carisa Bohannon or Ashley Miller by either phone or email.

After exhibiting symptoms, staff are required to meet all return-to-work criteria before returning.

If you start feeling sick during the work day, or experiences the symptoms listed below, you will be sent home immediately.

Please complete ONCE.
Email *
SELF-CHECKLIST Questions
Do you have a temperature of 100.0°F or greater?

Are you taking fever-reducing medicines, such as those that contain aspirin, ibuprofen or acetaminophen, in order to reduce the student's fever?

Have you had close contact or cared for someone with COVID-19 within the past 14 days?

Have you returned from travel outside the United States or on cruise ship or river boat within the past 14 days?

Have you been directed to self-quarantine by a health care provider?

Have you been directed to self-quarantine by the County or State Department of Public Health?

Are you experiencing any of the following symptoms?
Chills
New Cough (different from allergy or asthma baseline)
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
New onset of Headache
New loss of taste or smell
Sore Throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Link to printable form: http://www.bccu2.org/uploads/7/1/5/3/71536593/employee_daily_self_certification_form.pdf
Your Name:  Typing your name below serves as an electronic signature. *
I hereby acknowledge that I have received a copy of this COVID-19 Daily Self Checklist. I understand that I am required to honestly and accurately complete this checklist for myself each day before reporting for work. *
A copy of your responses will be emailed to the address you provided.
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