Westampton Adult Ed Student Daily COVID Screening Form
Adult Education Student,

This form is required to be completed each day you have class and enter the building and/or clinical site.

Please complete this form each day you have class no later than 45 minutes before your class or clinical begins.

Thank you,

Mr. Pappler
Student Name (First and Last) *
Campus - Westampton *
Required
Any of the symptoms below could indicate a COVID-19 Infection and may put you at risk for spreading the illness to others. Please note that this list does not include all possible symptoms and individuals with COIVD-19 may experience any, all, or none of these symptoms. Please check yourself daily for these symptoms.
Section A - If TWO OR MORE of the symptoms in this section are checked off, you must stay home and notify Adult Ed Administration for further instruction. *
Required
Section B -If AT LEAST ONE symptom in this section is checked off, you must stay home and notify Adult Ed Administration for further instruction. *
Required
Program - Please select from the drop down list *
Close Contact/Potential Exposure
If ANY of the fields in the 'Close Contact/Potential Exposure' section are checked off, you should remain home for 14 days from the last date of exposure (if you are a close contact of a confirmed COVID-19 case) or date of return to New Jersey.



Contact your provider or your local health department for further guidance.
Close Contact/Potential Exposure (Please verify if:)
Complete this section only if you work in a HEATHCARE Facility
Select "Yes" in the dropdown to verify that all information on this form is correct to the best of your knowledge. *
Submit
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