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SERMS Staff Daily Monitoring Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Temperature
*
Your answer
Do you have chills?
*
Yes
No
Do you have shortness of breath or difficulty breathing?
*
Yes
No
Do you have a new cough?
*
Yes
No
Do you have a new loss of taste or smell?
*
Yes
No
Have you had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?
*
Yes
No
Since you were last at school, have you been diagnosed with COVID-19?
*
Yes
No
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