Required Health Screening for Visitors/Substitutes (MUSD students, classified employees, certificated employees, or management employees do not complete this.)
Welcome to Milpitas Unified School District, in an effort to ensure that our facilities adhere to health and safety guidelines, all individuals entering a school district facility must participate in a COVID-19 Health Screening. Your information will be provided to the school district facility to ensure that all have been properly screened.  You will not have access to the building without participating in the screening prior to accessing the building.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Please list your telephone number or email address.  This should be the best way to contact you. *
Briefly state why you are visiting the site.  Please do not provide confidential information. (example - meeting with teacher) *
What is the name of the Milpitas Unified School District location that you will be visiting? *
Required
Within the last 10 days have you been exposed diagnosed with COVID-19 or had a test confirming you have the virus? *
Within the past 14 days , have you had close contact with, someone who has been in isolation for COVID-19 or had a test confirming they have the virus? Close contact is less than 6 feet for 15 minutes or more. *
Have you had any one or more of these symptoms today or within the past 3 days? • Fever or chills • Cough • Loss of taste or smell • Shortness of breath or difficulty breathing *
Have you had any one or more of these symptoms today or within the past 3 days and that is new or not explained by another reason?• Fatigue • Muscle or body aches • Headache • Sore throat • Nausea, vomiting, or diarrhea *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MUSD. Report Abuse
Google Forms