21-22 Staff Daily COVID-19 Symptom Screening
To safeguard the health of co-workers and people whom we serve, employees must complete the checklist below before reporting to work each day or submit immediately upon arriving at the school each day on campus. If you develop 2 or more of the symptoms below, STAY HOME. Please do NOT enter the building for your safety and the safety of others. The information on these forms will be kept confidential. Wearing a face mask is recommended if you are unvaccinated. Scecina will provide a face mask, if needed.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Role at Scecina for which you are filling out the form *
Please answer the questions below to indicate your current state, without an alternate diagnosis provided by a doctor.
Are you unvaccinated and been in close contact (within 6 feet for more than 15 minutes) with anyone that is currently positive for COVID-19 since your last visit to campus or attendance at a school-related event? *
Are you experiencing TWO OR MORE of the following symptoms:  Fever (over 100.4 degrees), chills, coughing, shortness of breath / difficulty breathing, muscle pain, headache, sore throat, or new loss of taste or smell? *
Conclusion
If you answered "Yes" to any of the above, then it is not safe to enter the building or attend a school-related activity. Please do not come into work or attend the event.  Please contact your supervisor immediately to notify of your status. Also, please contact your health care provider immediately to determine if the symptoms may be indicators of COVID-19 or if the symptoms are due to another cause. If you are a teacher, contact Casady Williamson or David Dellacca for arrangement of a substitute for your classes.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Scecina Memorial High School.

Does this form look suspicious? Report