Staff & Visitors Covid Screening Form 2021-22
This is a required screening by Wayne County Health Department. Please fill out this form before entering the building every day.

Do you have any new, unusual or worsening symptoms from the lists below?

If you answer "YES" to one or more questions, you MUST stay home.
Email *
Name *
List 1: Do you have at least 1 of these symptoms? Cough? Shortness of Breath? Difficulty breathing? Loss of Smell or Taste? *
List 2: Do you have at least 2 of these symptoms? Fever (100.4F or higher)? Vomiting or diarrhea? Headache? Sore throat? Runny nose and/or congestion? Body aches and/or tiredness? *
If the answer to any of the questions above is “yes”, stay home and consult your primary care physician.If a doctor determines that your symptoms are due to another diagnosis, or COVID-19 is ruled out, you may enterthe school after being fever-free for 24 hours without the use of fever-reducing medications.
Never submit passwords through Google Forms.
This form was created inside of Shajara Tayyiba. Report Abuse