STFOA Student/EWCC Health Self Screening Questionnaire
PARENTS/GUARDIANS:  
-  Please complete submit one form for each child before you come to school
-  "YOU" refers to your child (you are answering the questions about your child)

EDP STAFF:
-  Please submit one form for yourself before you come to school.

Symptom screening can be helpful to determine if you:
-  may currently have an infectious illness that could impair your ability to work
-  are at risk of transmitting an infectious illness to other individuals on the school site

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** IMPORTANT:  After you submit your responses for EACH student, please CLOSE APP on your phone.  (This will prevent multiple duplications of entries from being submitted).  Thanks so much!
Who is completing this form? *
STUDENT or Staff LAST NAME? *
Student or Staff FIRST NAME? *
Parent/Guardian FULL NAME? *
Student's Class? *
Current TEMPERATURE? *
In order to successfully pass screening, you must be able to answer “NO” to each of the following 6 questions. A “YES” to even one question is a failed screening and you are not allowed to enter the building unless you have been CLEARED.  Contact your COVID-19 Team for support (206) 243-5690.
1.  In the last 14 days, have you had a temperature at least 100.4°F? *
Required
2.  In the last 14 days, have you had new or increased shortness of breath or difficulty breathing? *
Required
3.  In the last 14 days, have you had a new cough? *
Required
4.  In the last 14 days, have you had at least TWO of the following symptoms together?  Check NO or YES.  ** If YES, check the box for each symptom you have experienced. *
Required
If YES, you have had two or more secondary symptoms, were you CLEARED to return to school?
*Close contact is defined as any individual who was within 6 feet of an infected person for a cumulative of 15 minutes within 24 hour period of time- starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive SARS-CoV-2 (COVID-19) test) until the time the patient is isolated.
SEE the NEXT Question
5. In the last 14 days, have you had CLOSE CONTACT* with a person with confirmed COVID-19? *
Required
6. In the last 14 days, have you traveled OUT OF WA STATE? *
Required
If YES, did you receive an email with dates to safely return to school? *
Required
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