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.

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Last Name *

First Name (please include child(ren)'s name if bringing them to campus) *

School Site/Department *

Calistoga Junior/Senior High School/Palisades

Calistoga Elementary School

Facilities

Food Services

District Office

Are you experiencing any of the following symptoms? *

Fever

Cough or Sore Throat

Runny Nose

Difficulty Breathing

Loss of Taste or Smell

Nausea, vomiting, or diarrhea

None of the above

Required

In the last 10 days, did you care for or have close contact with someone diagnosed with COVID-19? *

Yes

In the last two weeks, have you traveled outside of the state? *

Yes

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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