Northwest COVID-19 Employee Self Assessment

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- This tool will help you perform a self-assessment to determine if you are clear to report to work and is based on CDC and ODH guidelines.
- Each employee MUST take the assessment each day before reporting to work.
- Masks are required when onsite, especially in public/common areas or areas that are not your private work space, the exception is if you are medically unable to wear a mask.
- Employees are asked to sanitize their work areas throughout the day and before leaving.

More info: https://coronavirus.ohio.gov/

Email *

First Name: *

Last Name: *

Today's Date: *

YYYY

In the past 24 hours, have you had any of the following NEW symptoms? If you have checked any of these questions, DO NOT report to work and notify your building principal and school nurse).

Fever of 100.F or above, or possible fever symptoms like alternating chills and sweating

Cough / Sore Throat

Trouble breathing, shortness of breath, or severe wheezing

Muscle Aches

Diarrhea

Loss of smell or taste or a change in taste

Headache

Nausea and Vomiting

Do any of the following pertain to you? If you have checked any of these questions, DO NOT report to work and notify your building principal and school nurse.

Within the past 14 days, you have been in close physical contact with or without a mask (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19.

Within the past 14 days, you have had laboratory-confirmed COVID-19.

You are isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19

You are currently waiting on the results of a COVID-19 test.

Temperature (if greater than 100, please return home and contact your supervisor): *

Send me a copy of my responses.

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