AUSD Employee COVID-19 Health Screening Form
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This form is designed to identify possible symptoms of COVID-19 and/or other potentially contagious illnesses.

By submitting this form you are attesting that the following information is true and that to your knowledge you are not experiencing any signs of potentially contagious illness. Please note that it is the recommendation of AUSD Health Services that you not attend school/school-sponsored events if you have symptoms or could possibly spread contagious illness.

This form has been adapted from the LA County Department of Public Health's COVID-19 Reopening protocols. This form does not constitute medical advice and is for screening purposes only.
Email address *
Please write your full name *
In the past 10 days have you experienced any of the following symptoms: *
1 point
Required
In the last 10 days, has anyone in your household(s) experienced any of the above symptoms? *
1 point
In the last 10 days, have you or anyone in your household had contact with a confirmed or suspected case of COVID-19? *
1 point
Please take your temperature. Is your body temperature above normal, i.e., at or over 100.4°F or 38°C *
1 point
A copy of your responses will be emailed to the address you provided.
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