Gobles Public Schools
Coronavirus Disease (COVID-19)
Workplace Health Screening
Employee Health Screener Questions:
1. In the last 14 days, I have developed one of the following symptoms that are new/different/worse from baseline of any
chronic illness:
a. Subjective fever (felt feverish); new or worsening cough; shortness of breath, or difficulty breathing
b. Chills, headache, sore throat, loss of smell or taste, runny nose, or congestion, muscle aches, abdominal pain, fatigue,
nausea, vomiting, diarrhea.

2. I have a temperature of 100.4F or higher?

3. In the past 14 days, I have had close contact with an individual diagnosed with COVID-19?

4. In the past 14 days, I have traveled internationally?
Answer to Questions Above: *
Have you experienced any of the symptoms/experiences in the previous 4 questions?
• If you answer YES to any of these questions, please do not go into work and contact your supervisor for further instructions.

• Contact your primary care physician’s office if you have symptoms or if you are given a probable diagnosis or test positive for COVID-19.

• If you have any questions concerning the Employee Self Health Screening contact your supervisor
Employee Name: *
I certify that I have not had any of the above mentioned symptoms or an elevated temperature. Additionally, I certify that I have not been exposed to someone who has tested positive for COVID-19 or that I have not traveled internationally.
Practice these healthy habits to prevent the spread of viruses:

• Wash your hands with soap and warm water for 20 seconds. If unavailable, use an alcohol-based hand
sanitizer with at least 60% alcohol.

• Avoid touching your eyes, nose, and mouth with unwashed hands.

• Cover your nose and mouth with a tissue when you cough or sneeze, or cough/sneeze into your upper sleeve.

• Immediately throw away used tissues in the trash, then wash hands.

• Clean and disinfect frequently touched surfaces, such as doorknobs, handles, light switches, tables, toilets, faucets, sinks and cell phones.

• Avoid touching common surfaces in public places – elevator buttons, door handles, handrails, etc. Use elbows or knuckles to push buttons when you do not have a tissue or sleeve to cover hand or finger.

• Make sure others in your household, or anyone you are regularly in close contact with, follow these
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