NPSD STAFF COVID-19-Daily Pre-Screening Questionnaire
In order to keep our staff safe, health screenings are a necessity for staff when entering the school building. All staff must complete our mandatory self-screening form prior to leaving their home each morning. This form must be completed prior to entering the school building.

Staff should not report to school if exhibiting symptoms consistent with the DOH exclusion criteria for COVID-19.
*EXCLUSION CRITERIA*:

At least two of the following symptoms: fever (measure or subjective), chills, rigors (shivers), myalgia (muscle aches), headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose; OR

At least one of the following symptoms: cough, shortness of breath, difficulty breathing, new olfactory disorder (loss of smell), new taste disorder (loss of taste).

Staff should not report to work if they recently have tested positive for COVID-19 or have had recent close contact (being within 6 feet for at least 10 minutes) with a person who has tested positive for COVID-19 in the past 14 days.

Staff should not report if they have traveled to an area with high levels of COVID-19 transmission in the past 14 days:
 NJ travel advisory list: https://covid19.nj.gov/faqs/nj-information/travelinformation/which-states-are-on-the-travel-advisory-list-are-there-travelrestrictions-to-or-from-new-jersey
 International travel advisory: https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html
First Name *
Last Name *
School/Building *
Date you will be at school/building: *
MM
/
DD
/
YYYY
Have you had the following symptoms in the last 24 hours? *
Yes
No
Fever > or = 100.4
Chills
Rigors (shivers)
Myalgia (muscle aches)
Headache
Sore Throat
Nausea and/or vomiting
Diarrhea
Fatigue
Congestion or runny nose
Shortness of breath
Difficulty breathing
New loss of smell
New loss of taste
Please answer the following: *
Yes
No
Have you had close contact with someone who is currently sick with COVID-19 or experiencing symptoms consistent with COVID-19?
Have you been diagnosed with/tested positive for COVID-19 in the past two weeks or have reason to believe you have COVID-19?
Have you traveled internationally in the last 14 days?
Have you traveled to one of the states on the NJ travel advisory list in the last 14 days? For a complete list of the travel advisory states, please check the following link: https://covid19.nj.gov/faqs/nj-information/travel-information/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey
Please take your temperature and input the reading below. (if greater than or equal to 100.4℉, DO NOT report to the school district buildings/grounds) *
I will be in attendance in the school building today: *
What time will you be arriving at your building? (If you will not be arriving at your building, please input 12:00 AM) *
Time
:
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. *
Submit
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