Lincoln-Cook County School District 130: Daily Employee Health Screening Form
Cook County School District 130
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Name: *
Position: *
Date *
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Assigned Building/Work Location: *
1. Are you currently experiencing a fever greater than 100.4 degrees? *
2. Are you currently experiencing a new loss of taste or smell? *
3. Are you currently experiencing any vomiting? *
4. Are you currently experiencing any diarrhea? *
5.   Are you currently experiencing a new onset of a moderate to severe headache? *
6. Are you currently experiencing a new cough that is not related to allergies? *
7. Are you currently experiencing shortness of breath? *
8. Are you currently experiencing fatigue from an unknown cause? *
9. Are you currently experiencing a sore throat? *
10. Are you currently experiencing body aches from an unknown cause? *
11. I have received the COVID-19 vaccination within the last three days and began experiencing symptoms within the first forty-eight hours following my vaccination. If you answer "yes" to this question, you may report to work if you feel well enough, your vaccine-related symptoms occurred within the first forty-eight hours of your vaccine, and you have not had a fever within the past twenty-four hours. If you are experiencing vaccine-related symptoms and you do not feel well enough to work, please contact your supervisor. If your symptoms do not improve and continue for more than two days, please contact your supervisor immediately. *
12. Have you been in close contact with someone with a known or suspected case of COVID-19 within the last 14 days? (Close contact is defined as someone who was within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, starting from 2 days before illness onset (or for asymptomatic patients, two days prior to test specimen collection), until the time the infected person is isolated. “Close contacts” also include individuals who provided care at home to someone who is sick with COVID-19, individuals who had direct physical contact with the person (hugged or kissed them), individuals who shared eating or drinking utensils, and individuals on whom a person with COVID-19 sneezed or coughed, or somehow got respiratory droplets on.) *
If you have answered "yes" to any of the questions above, please contact your supervisor immediately. After you have contacted your supervisor, please contact Carrie Tisch at 708-259-6193.
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