Please answer all questions as accurately as possible before entering the school/building. 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 each school day.
Please choose the building you will be visiting from the drop box below.
Pittsgrove Township Central Office
Pittsgrove Township Child Study Office
Pittsgrove Township Transportation Office
Arthur P. Schalick HS
Pittsgrove Township Middle School
Olivet Elementary School
Elmer Elementary School
Norma Elementary School
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.)
Fever equal to or higher than 100.0 or feeling feverish (chills, sweating)
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Have you had close contact (within 6 feet for at least 10 minutes) 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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This form was created inside of Pittsgrove Township Schools.