Lenawee Intermediate School District COVID-19 Screening Questionnaire
The health and safety of our employees, students, contractors, volunteers, parents/guardians, and visitors remain the priority of the Lenawee Intermediate School District (LISD). As the Coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads, the LISD is closely monitoring the situation and will periodically update District guidance, including campus and building access requirements, based on current recommendations from the Lenawee County Health Department, the State of Michigan, and the United States Centers for Disease Control and Prevention.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our students, workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building.

If your response to any question is yes, you are prohibited from entering a LISD school/building and/or being present on a LISD campus. If you are an employee, please contact your supervisor as soon as possible. If you are a visitor, please contact the LISD employee who arranged for your visit or for whom you were visiting.
Sign in to Google to save your progress. Learn more
Name *
Cell Phone Number *
Staff or Visitor? *
Supervisor or Staff Coordinating Access
LISD Campus/School(s) to be Worked In/Visited (select all that apply) *
1. Have you been in close contact of another person who has tested positive (or is probable) for COVID-19 within the past 14 days? "Close contact" is defined as being within six feet for a period of 15 minutes or more during a 24-hour period, which may include multiple interactions of less than 15 minutes which cumulatively equal 15 minutes or more. ***Individuals who are fully vaccinated (meaning at least two weeks have passed since your second vaccine if you received the Pfizer or Moderna vaccine or since your single vaccine if you received the Johnson and Johnson vaccine) are not required to quarantine and may select no after close contact unless experiencing symptoms that are confirmed or suspicious of being of COVID-19. *
2. Do you currently have any signs or symptoms of COVID-19, which are one (1) or more of the following: an uncontrolled cough (excluding chronic cough due to a known medical reason or allergies), new onset of shortness of breath or difficulty breathing, or a fever of 100.4 degrees or higher; OR two (2) or more of the following: loss of taste or smell, abdominal pain, muscle aches, severe headache, sore throat, vomiting, or diarrhea? *
3. Have you recently been tested for COVID-19, have not yet received a negative result, and the testing was not part of a routine or regular testing protocol for a job or for any other reason that does not include being in close contact with a COVID-19 positive or probable person or having signs or symptoms of COVID-19? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lenawee Intermediate School District. Report Abuse