Health Self Assessment

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Covid19 Assesment

First and Last name *

1. Have you had close contact (within 6 feet for at least 10 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine? *

Yes - You should not work. You can return 14 days after the last time you had close contact with someone with COVID-19, or as listed below.

No - You can work if you are not experiencing symptoms.

2. Since you last worked, have you had any of these symptoms? *

Fever

Chills

Shortness of breath or difficulty breathing

New cough

New loss of taste or smell

None of the above

Required

3. Since you last worked, have you been diagnosed with COVID-19? *

Yes

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This form was created inside of North Carolina Center for the Advancement of Teaching.