Wellness Check. Must be completed prior to entering the building
This is a daily wellness check for anyone entering Explore Academy campus. Staff does not need to complete this form if working remotely.

Check you temperature in the area prior to coming into the lobby of the building.

If you answer yes to any of the questions below, please do not enter the building to teach, work, or visit.

Staff
- Please call in and follow normal school protocols for sick leave if you cannot teach remotely. Otherwise
continue your teaching schedule from home.
- Following the submission of this form, the Explore Academy Health Office will contact you for further
Instructions.

Once on campus, please proceed to your work space or check in with reception.
- Wash hands often
- practice social distancing
- wear an appropriate face mask

Thank you for your cooperation in keeping our community safe.
I am a . . . *
Full Name *
Cell Phone Number (this is required in the event of COVID tracing) *
1. Temperature Check: Is your current temperature ABOVE 100 degrees Fahrenheit or have you had a temperature above 100 degrees Fahrenheit in the last 48 hours ? *
2. Do you have a new uncontrolled cough that causes shortness of breath? *
3. Do you have any of the following symptoms? Fever, repeated shaking with chills, headache, new loss of taste or smell, diarrhea, muscle pain, sore throat, vomiting. *
4. Have you recently been in contact with a Covid positive individual (within 6ft and for more than 15 min)? Within the last two weeks?
Clear selection
5. Have you traveled out of the state of New Mexico within the last 2 weeks?
Clear selection
6. If you have traveled out of state, which state(s) did you travel to?
7. Is the state you traveled to in yellow or red or above 5% positivity rate? *
IF you answered "Yes" to any of the questions above, please stay home and a Health Office staff member will contact you. If you answered "No" to all questions, you may come into the building today. Thank you!
Submit
Never submit passwords through Google Forms.
This form was created inside of Explore Academy. Report Abuse