Band COVID-19 Screening Form
Fill out this form before each time you come to Band.
Email address *
Full Name *
LAST name, then FIRST name
Have you recently began experiencing any of the following in a way that is not normal for you? *
Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit, loss of taste or smell, cough, difficulty breathing, shortness of breath, fatigue, headache, chills, sore throat, congestion or runny nose, shaking or exaggerated shivering, significant muscle pain or ache, diarrhea, nausea or vomiting.
Have you had known close contact with a person who is lab confirmed to have COVID-19 within the last 14 days? *
Close contact is being directly exposed to infectious secretions; or being within 6 feet for a cumulative duration of 15 minutes; however, additional factors like case/contact masking (i.e., being consistently and properly masked), ventilation, presence of dividers, and case symptomology may affect this determination.
Is anyone in the household awaiting COVID-19 test results? *
Students should not enter campuses or district buildings if anyone, including themselves, is awaiting COVID-19 test results.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Alpine ISD. Report Abuse