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NW - COVID-19 Screening
NW Staff and visitors must fill out this form each time they enter a NW Building. NW staff and visitors are strongly encouraged to self screen before entering any district building. The forms will be timestamped after they are received.
Please answer the questions below appropriately if you are experiencing a new onset of symptoms.
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Building
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NWEE
NWEL
NWKMS
NWHS
NEC- Central Office
NWAHS
NWPCC
First Name
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Your answer
Last Name
*
Your answer
Phone Number
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Your answer
In the last 24 hours, have you experienced headache, chills or felt feverish?
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Yes
No
In the last 24 hours, have you experienced new or worsening cough, shortness of breath, sore throat, runny nose, congestion, or loss of smell or taste?
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Yes
No
In the last 24 hours, have you experienced muscle aches that are not explained by activity, abdominal pain or unexpected fatigue?
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Yes
No
In the last 24 hours, have you experienced nausea, vomiting or diarrhea?
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Yes
No
Have you had contact with anyone with confirmed COVID-19 in the last 10 days.
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Yes
No
If you answered “Yes” to any of these questions, you are not to enter district building until you have been cleared by a medical professional as not having or carrying the COVID-19 virus or provide a negative test. Please notify HR or your supervisor ASAP.
By checking this box, I verify that the above answers are true
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