Please answer all questions as accurately as possible.  You can complete this assessment for yourself or on behalf of someone else, such as a young child who may not have a device available.  This form MUST be completed prior to the start of the school year by all staff and students.  This is a one time form and only needs to be updated if there is a change to your status.
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Email *
Please choose the school or office where you are assigned. *
First Name *
Last Name *
Temperature *
Do you have any of these symptoms that are new, unexpected, or that you cannot attribute to another condition?  (Please check off all that apply.) *
Have you had close contact (within 6 feet for at least  15 minutes or greater within a 24 hour period) with someone who has tested positive for COVID-19 in the past 14 days? *
Within the past 14 days, have you traveled to an area subject to a Level 3 CDC Travel Health Notice or to a U.S. state with significant COVID-19 spread, as identified by the NJ Department of Health? *
Are you under evaluation for COVID-19 (waiting for results of a viral test to confirm infection)? *
Have you been diagnosed with COVID-19 and not yet cleared to discontinue isolation? *
Please read the statement below.
If you've answered yes to any questions, stay home, notify your supervisor and school nurse, and consult with your health care provider. Thank you!
A copy of your responses will be emailed to the address you provided.
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