On Campus Assessment Self Screening Questionnaire
Please answer the following questions every work day and prior to entering campus. If you can answer yes to any of these questions, we ask you to please stay home. Upon entering campus, please call the school secretary or principal so they are aware you are on campus. Upon leaving campus, please call the school secretary or principal.
Updated 10/12/20 Per CDC Guidelines
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Student First and Last Name
Moraga School District Site
1. Have you experience any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. (Not including any symptoms related to seasonal allergies)
2. Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
3. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
4. Are you currently waiting on the results of a COVID-19 test?
Did you answer NO to ALL QUESTIONS?Access to MSD facilities APPROVED.
Did you answer YES to ANY QUESTION?Access to MSD facilities is NOT APPROVED. 1. If you are not already at home, please avoid contact with others and go straight home immediately. 2. Call your primary care provider for further instructions, including information about COVID-19 testing. 3. Contact your school (if a student) or supervisor (if an employee).
This tool was developed by the Centers for Disease Control and Prevention (CDC)
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