COVID-19 Health Screening Questionnaire
The self-screening consists of a two-step process, temperature and a questionnaire.

Temperature:
Employees may take their own temperature before arriving to work. If the employee has a temperature above 100.4F, the employee is to remain at home and contact their supervisor. If the employee does not have a thermometer at home, contactless thermometers will be available at selected entry points of work sites.

Self-screening:
Employees may complete the self-screening survey at home or upon arriving at work. All employees will be required to take their temperature upon arriving at the work site. Contactless thermometers will be available at selected entry points. If they do not have a temperature above 100.4F, they are to proceed to their work station. If they did not complete the self-screening at home, they are to complete the self-screening upon starting work. If the employee has a temperature reading above 100.4F or answered yes to any of the questions of the self-screening, the employee is to return home and contact their supervisor.

In all instances where the employee stays home or returns home, the employee is to contact their supervisor and complete a Request/Verification of Attendance (VOA) form. If this is the first time the employee had a temperature above 100.4F or answered yes to any of the questions of the self screening, the employee should write “self-screening” on the VOA.
Email *
Full Name (I acknowledge I have read the above disclosure) *
Date
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Information and Acknowledgements
Banning Unified School District is committed to creating and maintaining healthy workplaces for employees, students and visitors during the COVID-19 pandemic. One contribution to that healthy environment is the cooperation of all employees regarding safe and healthy practices, including coming to work only when we are healthy. This check list is intended for employees who are planning to report to their workplace. By submitting this Self-screening Questionnaire you are acknowledging the following:

I will follow safe practices, including maintaining physical distancing of at least six (6) feet, wearing a face covering over my nose and mouth when in close proximity of other persons, frequently wash my hands or use hand sanitizer, avoid touching my face and consider my health and health of others.

I will inform my supervisor if I experience symptoms such as fever, cough, or shortness of breath at work, and I will go home.
Classification *
What is the best phone number to reach you? *
Work Area *
When was the last day you reported to your site?
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Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish” or had a temperature that is elevated for you or 100.4F or greater?
Clear selection
Do you have any of the following symptoms: sore throat; new or worsening cough; new respiratory illness; new loss of taste or smell; new or worsening shortness of breath; fatigue; muscle or body aches; severe headache; diarrhea; nausea or vomiting, non-allergy congestion or runny nose. *
Have you had close contact with any person who has been diagnosed with COVID-19 within the last 14 days? (Close contact is defined as being within 6 feet for more than 15 minutes with a person or having direct contact with infectious fluids from a person with confirmed COVID19, e.g. being coughed or sneezed on.) *
Have you taken any medication in the last three days that might mask symptoms of COVID-19 or symptoms of any respiratory illness? *
Have you tested positive for COVID-19 within the last 14 days? *
Have you been tested for COVID-19 and the results are pending? *
A copy of your responses will be emailed to the address you provided.
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