AAPS Staff COVID-19 Prescreening Tool
UPDATED 10-8-2020

Who is this form for? All AAPS employees, regardless of position, and all visitors to AAPS property.

When should it be used? At the beginning of the day or prior to building entry.

Why must all employees and visitors fill out the prescreening form?
This is required by the district's COVID-19 Preparedness and Response plan and corresponding Executive Orders. The tool serves as a reminder to keep scanning ourselves for COVID-19 symptoms and to let the school know if we may be at risk to prevent the spread of infection.

Note: It is the expectation that all district employees comply with this prescreening requirement and answer it truthfully. Failure to do so will result in discipline up to and including discharge.
Email address *
Today's date *
MM
/
DD
/
YYYY
Your first and last name *
Building/campus you are entering today: *
In the past 24 hours, have you experienced: *
Required
If you checked any one of the above symptoms, please do not enter the building or go into work. Call your health care provider, seek COVID-19 testing and isolate at home until test results become available).
In the past 24 hours, have you experienced: *
If you checked any TWO of the above symptoms, please do not enter the building or go into work. Call your health care provider, seek COVID-19 testing and isolate at home until test results become available.
In the past 14 days, have you been in close contact with anyone diagnosed with COVID-19? (Less than 6 feet for more than 15 minutes, with or without a mask in place): *
Clear selection
If you answered "yes," please do not enter the building or go into work. (Seek COVID-19 testing and isolate at home until test results become available).
Are you under evaluation for COVID-19? For example, waiting for the results of a diagnostic test to confirm infection. *
Have you been diagnosed with COVID-19 and not yet cleared to discontinue isolation? *
I certify and confirm that the answers I have provided in this form are complete, truthful and accurate. *
If you checked symptoms (that are new or can't be explained by a known condition) please stay home and call your health care provider for medical advice. Let your building administrator/supervisor know your status. If you answered yes to any of the questions, please stay home and contact your building administrator/supervisor.
By entering the building, you are acknowledging that none of the above applies to you or a family member.
Updated 10-8-2020.

Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Ann Arbor Public Schools. Report Abuse