Head Start Staff Health Attestation Related to COVID-19
Prior to accessing Region 9 ESC facilities or an ESC hosted off-site event, all employees and guests are requested to complete an Attestation of Health Status (adapted from Governor Abbott’s Open Texas guidance document and CDC guidelines) regarding COVID-19 symptoms and level of contact with others exhibiting symptoms.
• A separate form is required for each individual entering the ESC/facility for EACH DAY access is requested
• The form must be completed prior to building entry and not more than 12 hours in advance (If any conditions change prior to building entry but after the form is submitted, please resubmit)
• If an individual checks YES to the health question below, access to the ESC/facility is temporarily denied, and the individual should contact Region 9 for alternative methods to conduct tasks, to establish a timeline for reconsideration for entry, etc.
Name: *
Site: *
Date: *
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Please check YES or NO based on the following symptoms/conditions: *
Required
Symptoms/Conditions:

• Cough
• Shortness of breath or difficulty breathing
• Chills
• Repeated shaking with chills
• Muscle pain
• Headache
• Sore throat
• Loss of taste or smell
• Diarrhea
• Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit
• Known close contact with a person who is lab confirmed to have COVID-19 or is undergoing testing for a suspected diagnosis of COVID-19 within the past 14 days
• I have either been diagnosed with COVID-19, been suspected to have the virus, or have been treating COVID-19 type symptoms at home, and all of the following conditions have not been met yet:
* At least 3 days (72 hours) have passed since recovery (resolution of fever without the use of fever-reducing medications)
* Improvement in respiratory symptoms (e.. cough, shortness of breath)
* At least 10 days have passed since symptoms first appeared
By submitting this form, I agree to:
• Wash or sanitize my hands upon entering the ESC/facility and periodically while in the building
• Practice social distancing by maintaining at least six feet of separation from others. If such distancing is not feasible, I will implement measures such as face covering, hand hygiene, cough etiquette, cleanliness/sanitation
• Wear a face covering over my nose and mouth in all common spaces and when not at my desk or at a workspace where social distancing can be implemented and maintained.
• If I answered “YES” to the health question above, I will not enter the ESC/facility until cleared to do so.
I certify with the submission of this form that all of the information requested above has been completed and is accurate to the best of my knowledge. *
Required
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