EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE

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The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure at our school system, we are asking everyone to complete and submit this questionnaire prior to entering the campus.

Please do not enter the campus until your responses have been reviewed and your entry has been approved. 𝐏𝐥𝐞𝐚𝐬𝐞 𝐫𝐞𝐬𝐩𝐨𝐧𝐝 𝐭𝐨 𝐞𝐚𝐜𝐡 𝐨𝐟 𝐭𝐡𝐞 𝐟𝐨𝐥𝐥𝐨𝐰𝐢𝐧𝐠 𝐪𝐮𝐞𝐬𝐭𝐢𝐨𝐧𝐬 𝐭𝐫𝐮𝐭𝐡𝐟𝐮𝐥𝐥𝐲 𝐚𝐧𝐝 𝐭𝐨 𝐭𝐡𝐞 𝐛𝐞𝐬𝐭 𝐨𝐟 𝐲𝐨𝐮𝐫 𝐚𝐛𝐢𝐥𝐢𝐭𝐲.Your participation is important to help us take precautionary measures to protect you and our other employees.

Email *

Today's Date: *

YYYY

Your Name *

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms in a way that is not normal to you? *If unsure if a symptom is not normal to you, contact your supervisor to determine next steps. *

I am not experiencing symptoms that are not normal to me.

Yes, I am experiencing one the symptoms above, which is not normal to me. I will contact my supervisor before reporting on-site.

Have you been tested for COVID-19 and are waiting to receive test results? *

Yes - If you answer yes, please contact your supervisor before reporting on-site.

In the past 14 days, have you tested positive for COVID-19 and have not been cleared by a medical professional to return to work? *

Yes - If you answer yes, please contact your supervisor before reporting on-site.

In the past 14 days, have you been directly exposed to an individual's secretions who is lab-confirmed to have COVID-19 (e.g., being coughed on while not wearing a mask or face shield)? *

Yes - If you answer yes, please contact your supervisor before reporting on-site.

In the past 14 days, have you been within 6 feet for a cumulative duration of 15 min, while not wearing a mask or face shield, of an individual who is lab-confirmed to have COVID-19? *

Yes - If you answer yes, please contact your supervisor before reporting on-site.

Will you be bringing your own Clint ISD child or children to the work-site with you? *

No - If you answer no, scroll all the way down and click 𝐒𝐮𝐛𝐦𝐢𝐭

Yes - If you answer yes, please fill out the information below about your child/children before submitting.

𝐂𝐡𝐢𝐥𝐝𝐫𝐞𝐧 𝐨𝐟 𝐂𝐥𝐢𝐧𝐭 𝐈𝐒𝐃 𝐒𝐭𝐚𝐟𝐟

District employees are allowed to bring their school-aged children to work with them if they are from the same household and are enrolled as Clint ISD Students.

*The decision to bring children on-site must be made in conjunction with the staff member and campus principal. This
decision will be based on the staff member’s workspace/area and availability throughout the day to supervise their children.

Children will need to wear a mask at all times in the building other than when in the classroom/isolated area with their parent.

My child or children who I would like to bring on-site are currently enrolled at a Clint ISD School.

Yes

No - We apologize, but only children who are currently enrolled in a Clint ISD school may come to the worksite with you. Please contact your supervisor if you have questions on this or would like to enroll your child in a Clint ISD school.

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Have you received approval from your supervisor/principal to bring your children with you?

Yes

No - I will call them and discuss this before moving forward.

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Name of Clint ISD child or children - Please list their first and last name:

Do you confirm that your child/children meet all screening criteria above? (No temperature, no symptoms, no close contact, etc.)

Yes

No - If you answer no, then your children cannot report to the worksite. Please contact your supervisor.

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A copy of your responses will be emailed to the address you provided.

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