Cook County School District 130: Daily Employee Health Screening Form
Cook County School District 130
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Name: *
Position: *
Date *
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Assigned Building/Work Location: *
1. Are you currently experiencing a fever greater than 100.4 degrees or chills? *
2. Are you currently experiencing a new loss of taste or smell? *
3. Are you currently experiencing any nausea or vomiting? *
4. Are you currently experiencing any diarrhea? *
5. Are you currently suffering from a headache? *
6. Are you currently experiencing a cough that is not related to allergies? *
7. Are you currently experiencing shortness of breath? *
8. Are you currently experiencing a runny nose that is not related to allergies? *
9. Are you currently experiencing a sore throat? *
10. Are you currently experiencing body aches? *
11. Have you been in close contact with someone with a known or suspected case of COVID-19 within the last 14 days? (Close contact is defined as someone who was within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, starting from 2 days before illness onset (or for asymptomatic patients, two days prior to test specimen collection), until the time the infected person is isolated. “Close contacts” also include individuals who provided care at home to someone who is sick with COVID-19, individuals who had direct physical contact with the person (hugged or kissed them), individuals who shared eating or drinking utensils, and individuals on whom a person with COVID-19 sneezed or coughed, or somehow got respiratory droplets on.) *
If you have answered "yes" to any of the questions above, please contact your supervisor immediately. After you have contacted your supervisor, please contact John Dudzik at 708-259-7786.
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