AAPS Staff COVID-19 Prescreening Tool
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.
Your first and last name
Building/campus you are entering today:
Ann Arbor Open
Balas Administration Building
Freeman Environmental Education Center
Pathways to Success
Rec & Ed Office
Westerman Preschool and Family Center
Cultural Arts Building (CAB)
Veteran's Memorial Park
In the past 24 hours, have you experienced:
Fever (100.4 degrees or higher)
Cough (excluding a chronic cough related to another medical condition other than COVID-19)
Difficulty breathing or shortness of breath
Loss of taste or smell
None of the above
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: *
Fatigue (unrelated to another known cause)
Diarrhea (excluding diarrhea related to another medical condition other than COVID-19)
Nausea or vomiting
Congestion or runny nose
None of the above
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): *
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.
Send me a copy of my responses.
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This form was created inside of Ann Arbor Public Schools.