Online Health Self-Assessment Form
The Croton-Harmon School District asks that this form be completed and submitted by every staff member each day before reporting to work.
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Your Name *
Your location you report to at the beginning of the day *
In the last 48 hours have you had any of the following? *
Did you check any of the above boxes that lists a symptom, AND is the symptom unrelated to a pre-existing condition?
If yes, please call your supervisor prior to reporting to work
Have you been exposed to Covid-19 in the last 24 hours? *
In the last 14 days, did you care for or have close contact with someone diagnosed with COVID-19? *
Have you traveled out of the country in the last 14 days, or have you experienced any symptoms since your return from traveling out-of-state? *
Did you say, "Yes" to any of the three questions above?
If so, please contact your healthcare provider prior to reporting to work
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