MCM Daily COVID-19 Sympton Self-Screen
This online form should be completed by staff and students prior to coming to MCM.
Email *
The purpose of the COVID-19 Symptom Self Screen is to help you make decisions regarding the safety of going to work or class. This is not intended for the diagnosis or treatment of disease or other conditions, including COVID-19. By completing this form you acknowledge that the information provided may be used to assist in contact tracing for the MCM community. * *
Required
First Name *
Last Name *
Preferred phone contact. *
Have you had any of the following symptoms since your last day at work or the last time you were here that you cannot attribute to another health condition? *
Required
If you answered “Yes” to any of the screening questions, you should stay home, stay away from other people, and contact your health care provider.
All staff and students are required to have a temp check prior to entering the facility.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Montessori Training Center of Minnesota. Report Abuse