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.
MESSAGES TO PREVENT THE SPREAD OF VIRUSES AND TO STAY HEALTHY
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
precautions.
Submit
Never submit passwords through Google Forms.
This form was created inside of Gobles Public Schools. Report Abuse