Pleasant Hill District #69 Self-Certification Form
This form must be filled out daily before entering Pleasant Hill Elementary School
First and Last Name
Please read carefully and answer honestly:
IDPH requires that schools conduct symptom screenings and temperature checks or require that
individuals self-certify that they are free of symptoms before entering school buildings.
1. Have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional in the past 14 days?
2. Have you had close contact (within 6 feet for 15 minutes) with or cared for someone diagnosed with COVID-19 within the last 14 days?
3. Have you experienced any cold or flu-like symptoms in the last 14 days (to include: fever or temperature of greater than 100.4 degrees Fahrenheit/38 degrees Celsius, cough, difficulty breathing, sore throat, extreme fatigue, persistent headache, nausea, vomiting or diarrhea, and new persistent loss of smell or taste, muscle or body aches)?
How do you respond to these questions? (If you are able to answer "YES" to one or more of the above questions, select YES. If you are able to answer "NO" to all the questions, select NO.) IF YOU ANSWER "YES" TO ANY OF THE QUESTIONS, YOU ARE NOT ALLOWED TO ENTER THE BUILDING. *
Send me a copy of my responses.
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This form was created inside of Pleasant Hill School District 69.