COVID-19 Workplace Health Screening Form

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Self Assessment for ALL people to fill out before or upon arriving at the building.

Last Name: *

First Name: *

Affiliation with Mason Public Schools *

Building (Select all that apply) *

Central Office

Transportation

High School

Middle School

Steele

North Aurelius

Alaiedon

Harvey

Multiple Buildings

Required

In the last 24 hours, have you experienced any of the following? *

Yes

New or Worsening Cough

Shortness of Breath/Difficulty Breathing

New loss of taste or smell

Fever (100.0 or Higher) or felt feverish:

Actual temperature reading (fever is a temperature of 100.0 degrees F or higher). *

NOW REQUIRED

If you answered "Yes" to one or more the first four symptoms above, DO NOT GO INTO WORK. Self-isolate at home and CONTACT YOUR PRIMARY CARE PHYSICIAN'S OFFICE OR NEAREST URGENT CARE FACILITY for direction. Contact your supervisor for further direction. You should isolate at home for a minimum of 5 days since symptoms first appeared. You must also be fever free (without the use of fever reducing medication) and other symptoms must have improved before returning to work/school. MEDICAL DOCUMENTATION OF A CONDITION NOT RELATED TO COVID CAN RELEASE AN INDIVIDUAL FROM ISOLATION.

EMPLOYEES WILL NEED EMAIL RICK BROOKS or ERIN BERRYHILL BEFORE RETURNING TO WORK.

In the last 24 hours, have you experienced any of the following? *

Yes

Chills:

Muscle Aches:

Headaches:

Sore Throat:

Diarrhea:

Nausea or vomiting:

Congestion or runny nose:

If you answered "Yes" to two (2) or more of the seven symptoms above, DO NOT GO INTO WORK. Self-isolate at home and CONTACT YOUR PRIMARY CARE PHYSICIAN'S OFFICE OR NEAREST URGENT CARE FACILITY for direction. Contact your supervisor. You should isolate at home for a minimum of 5 days since symptoms first appeared. You must also be fever free (without the use of fever reducing medication) and other symptoms must have improved before returning to work/school. MEDICAL DOCUMENTATION OF A CONDITION NOT RELATED TO COVID CAN RELEASE AN INDIVIDUAL FROM ISOLATION.

EMPLOYEES WILL NEED EMAIL RICK BROOKS or ERIN BERRYHILL BEFORE RETURNING TO WORK.

In the past 14 days, have you Been in close contact or cared for someone who has tested positive for CoVid-19: *

A close contact is determined by being in a room without a mask or being in a room with a mask and closer than 6 feet for a total of 15 minutes.

Yes

Yes, but I have been fully vaccinated. (Have received a booster dose, OR have completed the primary series of the Pfizer or Moderna vaccine within the last 6 months, OR have completed the primary series of the J&J vaccine within the last 2 months.

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