Date *

name *

Does any member of your household have COVID-19-related symptoms and awaiting a COVID-19 test or test result? If yes, you may enter the workplace if you • have been vaccinated with at least one COVID-19 vaccine dose for more than 14 days AND • are asymptomatic If a member of your household tests positive for COVID-19, then you must also undergo two COVID-19 screenings: • between Day 3 and Day 5 from last date of contact AND • on Day 10 from last date of contact If yes, and you have not been vaccinated or you have been vaccinated for less than 14 days, then you must stay home, self-isolate and await their test results. *

Part A: Has your student or you (if staff) had any of the following symptoms in the last 24 hours? One or more of the below symptoms = stay home, self isolate. *

Part B: Has your student or you (if staff) had any of the following symptoms in the last 24 hours? two or more of the below symptoms = stay home, self isolate. *

Will you be working from the office today? If you have answered YES to either of the above questions or exhibit symptoms listed above DO NOT COME INTO THE OFFICE and follow the instructions provided below.

Do you have to stay home due to a family member or child showing symptoms/awaiting test results?

I acknowledge that I have read this, and understand that COVID_19 is highly contagious, and that if my child or me (if staff) has any of the above symptoms they will stay home and contact the KMHC Testing Center to determine if they need to be tested for COVID-19. Phone number of the testing site (450-638-3930 ext. 2296 or ext. 2275)) Let’s make school FUN, EDUCATIONAL and SAFE. I UNDERSTAND *