Employee Wellness Certification Form
INSTRUCTIONS:
1. THIS FORM MUST BE COMPLETED BY PARKLAND EMPLOYEES PRIOR TO PHYSICALLY REPORTING TO WORK OR ENTERING ANY PARKLAND FACILITY.  ALSO, COMPLETE THIS FORM PRIOR TO SELF-QUARANTING.

2. ONLY ONE FORM IS REQUIRED TO BE COMPLETED PER DAY (regardless of the number of buildings you enter).

The Parkland School District is taking proactive steps to protect the workplace during this infectious disease outbreak. It is the goal of the Parkland School District during this time period to strive to operate effectively and ensure all essential services are continuously provided and employees are safe within the workplace. Therefore, beginning May 26, 2020, we are requiring ALL staff to review the Return to Work information found below and answer the questions in this form.

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Email *
Please review Parkland's Return to Work Employee Wellness Guidelines found at the link below: https://docs.google.com/document/d/14SJqKDIYEKA_Vk5JfYNJrUBOXHHDfmlfmi4pRYUIrIY/edit *
Required
What is your First Name? *
What is your Last Name? *
Primary Assigned Building *
Department/Area *
Supervisor's First and Last Name *
Employee Health Screening Questions
As of March 20, 2020, the CDC has recommended regular health screenings of temperature and respiratory symptoms upon arrival each day in many places. Since exposure to COVID-19 is not necessarily a medical condition, questions regarding exposure are permissible as per CDC guidelines. Please answer the Employee Health Screening Questions 1-5 below to the best of your ability.  
1. Are you currently experiencing one of the following symptoms (fever-100.4F or higher, cough, shortness of breath, chills, lack of taste or smell) or two or more of these symptoms (headache, congestion, runny nose, sore throat, body aches, nausea, vomiting, diarrhea or fatigue)? *
2. Have you had any of the above signs or symptoms in the past two weeks? *
3. Take your temperature now. Is it 100.4F or above? *
4. Are you presently caring for or living with someone who has experienced the signs or symptoms of COVID-19 within the past two weeks? *
5. In the last two weeks, have you or someone you live with been under quarantine (not related to travel) for COVID-19? *
If you answer "YES" to ANY of the Employee Health Screening questions above, please DO NOT report to work.  In addition, follow your department or building procedures for reporting off from work and provide the best number by which you can be reached in the space below. You will receive a phone call from the Director of Human Resources and/or the Supervisor of Health & Wellness.  If you answer "No" to ALL of the Employee Health Screening questions, please report to work.  
Please use the space below to provide the best number by which you can be reached in case someone from administration needs to contact you. *
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