COVID-19 Staff Screening Form
Daily staff self-screening for COVID-19 symptoms prior to entering campus is an essential part of the process to ensure campuses remain safe. The information collected from this survey is considered confidential and the details will only be viewed by management and confidential employees. This system is not intended for the diagnosis or treatment of disease or other conditions, including COVID-19. This system is intended only for adults who are 18 years and older and currently located in the United States.
If you are experiencing a life-threatening emergency, please call 911 immediately. If you are not experiencing a life-threatening emergency, please move forward and complete the survey.
First Name (please include child(ren)'s name if bringing them to campus)
Calistoga Junior/Senior High School/Palisades
Calistoga Elementary School
Are you experiencing any of the following symptoms?
Cough or Sore Throat
Loss of Taste or Smell
Nausea, vomiting, or diarrhea
None of the above
In the last 10 days, did you care for or have close contact with someone diagnosed with COVID-19?
In the last two weeks, have you traveled outside of the state?
If you answered yes to any of the above questions, please contact human resources at 707-942-4703 before going to your worksite.
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This form was created inside of Calistoga Joint Unified School District.