COVID-19 Daily Health Screening Form 😷

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Please do not come to work / class If you have had symptoms consistent with COVID-19, have been exposed, or have tested positive for COVID-19. Thanks! –The Barrow Group

Email *

Full Name *

Class you are enrolled in *

Have you had a body temperature of more than 100.4 degrees in the last three days? *

Students / employees should take their temperature before they go to class. If they have a temperature above 100.4F, they should stay home.

Yes

Are you feeling sick? *

Yes

In the last two weeks, did you have close contact with someone with symptoms of COVID-19, test positive for COVID-19, or get diagnosed with COVID-19? *

Close contact is when you are within 6 feet of an infected person for at least 15 minutes.

Yes

Do you have any of the following symptoms? *

Feeling feverish (such as chills, sweating)

Cough

Mild or moderate difficulty breathing

Sore throat

Muscle aches or body aches

Vomiting or diarrhea

New loss of taste or smell

Congestion or runny nose

None of the above

Required

Electronic Declaration *

I hereby declare that the details furnished above are true and correct to the best of my knowledge.

Required

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This form was created inside of The Barrow Group.