Coronavirus Disease (COVID-19)Workplace Health Screening for Hillsdale County ISD Visitor
Please complete this form upon entering an HCISD building.
Current Temperature - If your temperature is 100.4 or greater please go or stay home and contact your Primary Care Provider.
In the past 24 hours, if have you experienced any of the symptoms below please check the box next to the symptom that you have experienced. If you have not had symptoms please check the last box.
Fever or chills
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
I confirm that I have not experienced any of the above symptoms in the past 24 hours.
In the last 14 days have you; please check the appropriate boxes below
I have had close contact with an individual diagnosed with COVID-19
I confirm that I have not had close contact with an individual diagnosed with COVID-19
If you have been in close contact with someone that has tested positive and have not been fully vaccinated or are within the 14 day waiting period from your final dose of vaccination, please stay home or go home and contact your local health department for quarantine information.
I have had close contact with an individual diagnosed with COVID-19, however, I can provide proof that I have been fully vaccinated and past the 14 day waiting period from my final vaccination and am not currently experiencing any symptoms.
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This form was created inside of JCISD.