OV Sign-In and COVID-19 Daily Screening Form

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Please complete the following form each morning for reporting purposes.

Use this self-assessment tool to determine what actions you can take to protect you and your loved ones' health and help determine whether you should be tested for COVID-19. Your answers will also enable us to protect our school and community. Please answer all the questions daily, prior to entering the building. This can be done on the computer or your phone.

Name (First and Last) *

Please conduct a self-temperature check (ex. 98.6) and record results here. *

Any of the following symptoms below could indicate a COVID-19 infection and put you at risk for spreading the illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. COLUMN A SYMPTOMS *

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or runny nose

None of the above

Required

Please check if you are experiencing any of the following symptoms - COLUMN B Symptoms *

Cough

Shortness of Breath

Difficulty Breathing

New loss of smell

New loss of taste

None of the above

Required

Close Contact or Potential Exposure - Please verify if: *

You have had close contact (within 6 feet of an infected person for at least 15 minutes) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

You traveled to a state on NJ's list of quarantine.

None of the above

Required

Date *

YYYY

Time *

Time

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