COVID-19 Weekly Health Screening Form

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COVID-19 Weekly Health Screening Form - Staff

This is a mandatory questionnaire to be filled by Al-Madinah School staff every week. A general rule of thumb by Sunday night every week, you must fill it out. The health and safety of our employees, students, and visitors is always of paramount importance and is especially highlighted during the current time of the COVID-19 pandemic. The following questionnaire will be used to track the contact details and symptoms of everyone entering the building. By keeping track of the symptoms of everyone entering the building, we can take steps to prevent the spread of COVID-19. In an effort to reduce the risk of COVID-19 exposure, all employees and visitors must answer the following questions. Thank you.

First Name *

Last Name *

Department *

Phone Number: (preferred Cell for texting): *

In the past 14 days, have you, or someone in your household, had close, unprotected contact with a suspected or known COVID-19 patient ? *

If the answer is YES , DO NOT GO ANY FURTHER and CONTACT YOUR SUPERVISOR. IF NO please continue to next question

Yes

In the past 14 days, have you or anyone in your household traveled domestically or internationally? *

If the answer is YES , DO NOT GO ANY FURTHER and CONTACT YOUR SUPERVISOR. IF NO please continue to next question

Yes

Within the past 10 days, have you or anyone in your household experienced a fever of 100.4 F , a new cough, new loss of taste or smell, or shortness of breath ? *

If the answer is YES , DO NOT GO ANY FURTHER and CONTACT YOUR SUPERVISOR. IF NO please continue to next question

Yes

In the past 10 days, have you or anyone in your household tested positive for COVID-19. *

If the answer is YES , DO NOT GO ANY FURTHER and CONTACT YOUR SUPERVISOR. IF NO please continue to next question

Yes

I hereby confirm that the information provided above is accurate, correct and complete. *

Yes

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