Les Cheneaux Community Schools Employee & Visitor Screening Form

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The safety of our employees, educators, families, and visitors remains our overriding priority. As the Coronavirus disease (COVID-19) outbreak continues to evolve and spreads globally, LCCS is monitoring the situation closely and will periodically update organization guidance based on current recommendations from the Center for Disease Control and the World Health Organization.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our building. Thank you for your time.

If you answer "yes" to the following question, please contact your supervisor immediately.

Full Name *

In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness: fever, sore throat, cough, shortness of breath? *

Yes

Have you been in close contact (defined within 6' of someone for 15 minutes) with someone with COVID-19 or cared for someone with COVID-19 in the last 14 days?

Yes

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Temperature (if higher than 100.4 - STAY HOME) *

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