ESMS- 8118 Visitor Covid-19 Screening Form
Visitors must fill out the screening form .
If you marked yes to 1 or more of the COVID questions below, DO NOT physically enter schools or facilities at this time.
You need to stay home and follow instructions from the LA County Department of Public Health, as set forth in the following link:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html
* Required
Email address
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time In
*
Time
:
AM
PM
Time out
*
Time
:
AM
PM
Do you have a cough?
Yes
No
Clear selection
Are you experiencing shortness of breath?
Yes
No
Clear selection
Are you experiencing fever or chills?
Yes
No
Clear selection
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)?
Yes
No
Clear selection
Have you had close contact with, or cared for someone diagnosed with COVID-19 within the last 14 days?
Yes
No
Clear selection
Are you currently required to be under isolation or quarantine?
Yes
No
Clear selection
Send me a copy of my responses.
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