JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
SAHS Building Covid-19 Screening
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Have you traveled in the past 10 days
Yes
No
Clear selection
Have you Recently Tested for Covid-19 and awaiting results?
*
Yes
No
Date
Other:
Have you had any close contact in the last 14 days with anyone with Covid-19
*
Yes
No
Have you or a member of your household had any of the symptoms in Fever, Sweats, Chills within the last 24 hours 100.4 . Any Sore throat, cough, body aches .
*
Yes
No
Other:
Have you had Shortness of Breath or Chest Tightness?
*
Yes
No
Have you had a loss of Taste or Smell, Diarrhea/Nausea/Vomiting?
*
Yes
No
What is your Current Temperature?
Your answer
If you answered YES to any of the questions, you MUST speak with the health care staff member, for further instructions.
*
Yes
No
Other:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
