CCISD Covid-19 Workplace Health Screening
Sign in to Google to save your progress. Learn more
Email *
Name *
What is the primary location you will be at? *
Room number, if applicable
LEA districts/agencies visiting, if applicable (check all for the day)
What time do you expect to arrive at the building?  Pick the time before but closest to your expected arrival. *
What time do you expect to leave?  Pick the time after but closest to your expected departure. *
In the past 24 hours, have you experienced ONE or more of these symptoms that are NOT attributable to a known condition OTHER than COVID-19 *
According to the CDC, people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. People with the symptoms listed below may have COVID-19. Please mark all symptoms that you have experienced in the last 24 hours that are NOT attributable to a known condition OTHER than COVID-19.  
Required
If you indicated ANY of these symptoms listed above, please go home and self-isolate for a minimum of 10 days since symptoms first appeared AND until you have had 24 hours fever free (without medication) AND symptoms have improved.
In the past 24 hours, have you experienced TWO or more of these symptoms that are NOT attributable to a known condition OTHER than COVID-19 *
According to the CDC, people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. People with the symptoms listed below may have COVID-19. Please mark all symptoms that you have experienced in the last 24 hours that are NOT attributable to a known condition OTHER than COVID-19.  
Required
If you indicated 2 OR MORE of these symptoms listed above, please go home and self-isolate for a minimum of 10 days since symptoms first appeared AND until you have had 24 hours fever free (without medication) AND symptoms have improved.
In the past 10 days, have you *
In the past 10 days, have you:
Yes
Yes - already discussed with supervisor and cleared for work
No
Had close contact with any individual diagnosed or suspected to be infected with COVID-19?
If you answered YES to the question listed above, please go home, self-quarantine for a minimum of 10 days (if asymptomatic - or until symptoms clear), and contact your supervisor.
By submitting this screening, you attest that you have responded truthfully to all questions and, in the event you have a COVID-19 test, agree to share the results of that test with your administrator.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Regional Educational Media Center #1. Report Abuse
Google Forms