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
Email address *
First Name *
Last Name *
Date *
MM
/
DD
/
YYYY
Time In *
Time
:
Time out *
Time
:
Do you have a cough?
Clear selection
Are you experiencing shortness of breath?
Clear selection
Are you experiencing fever or chills?
Clear selection
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)?
Clear selection
Have you had close contact with, or cared for someone diagnosed with COVID-19 within the last 14 days?
Clear selection
Are you currently required to be under isolation or quarantine?
Clear selection
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of LAUSD. Report Abuse