AUSD Employee COVID-19 Health Screening Form
Please complete the form and then select the option to "view score" at the end. Feedback and next steps will be provided.
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.
Please write your full name
In the past 10 days have you experienced any of the following symptoms:
Fever, or temperature above 100.4 degrees Fahrenheit
Cough not explained by other ailments
Shortness of breath or difficulty breathing
Chills, and/or repeated shaking with chills
Muscle pain and/or headache not explained by other ailments
Sudden loss of taste and/or smell
None of the above
In the last 10 days, has anyone in your household(s) experienced any of the above symptoms?
In the last 10 days, have you or anyone in your household had contact with a confirmed or suspected case of COVID-19?
Please take your temperature. Is your body temperature above normal, i.e., at or over 100.4°F or 38°C
Yes, it is above normal
No, it is normal
A copy of your responses will be emailed to the address you provided.
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