Cook County School District 130: Daily Employee Health Screening Form
Cook County School District 130
Name: *
Position: *
Date *
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DD
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YYYY
Assigned Building/Work Location: *
1. Are you currently experiencing a fever greater than 100.4 degrees or chills? *
2. Are you currently experiencing a new loss of taste or smell? *
3. Are you currently experiencing any nausea or vomiting? *
4. Are you currently experiencing any diarrhea? *
5. Are you currently suffering from a headache? *
6. Are you currently experiencing a cough that is not related to allergies? *
7. Are you currently experiencing shortness of breath? *
8. Are you currently experiencing a runny nose that is not related to allergies? *
9. Are you currently experiencing a sore throat? *
10. Are you currently experiencing body aches? *
11. Have you been in close contact with someone with a known or suspected case of COVID-19 within the last 14 days? (Close contact is defined as being within 6 feet of a person, having cared for, having lived with, or spent 15 minutes or more with the person.) *
If you have answered “Yes” to any of the questions above, please contact Dr. Colleen McKay at 708-489-7309 immediately.
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