New Hope Elementary School District COVID-19 Daily Self-Screening Assessment
Under the order of the San Joaquin County Public Health Officer and the California Department of Public Health (CDPH), employees must undergo a self-screening before entering a work area. To comply with the order and to determine if an employee is well and symptom-free before coming to a worksite, all New Hope Elementary School District employees must conduct a self-screening at home each day using the Employee COVID-19 Daily Self-Screening Assessment. Employees may complete this online Google form or print and complete the paper version.
Under the order of the San Joaquin County Public Health Officer and CDPH:
• If you are COVID-19 positive, you must isolate for 10 days after symptoms first appeared and until you are fever-free for 24 hours without fever-reducing medication and see improvement in symptoms. If you have been diagnosed with COVID-19 and have no symptoms (asymptomatic), you must stay home for 10 days from the date of your positive COVID-19 test.
• If you have had close contact, less than 6 feet for 15 minutes or more, with someone who is COVID-19 positive or has been told by a health care provider to get tested for COVID-19, you must quarantine for 14 days from your last exposure to the COVID -19 positive person.
• If you have signs and symptoms of COVID-19 but test negative and you have had no known exposure to someone COVID-19 positive, you may return to work 3 days after symptoms resolve.
In any of the situations above, please inform your supervisor immediately, enter your time in Frontline, and indicate that the absence is COVID-19 related. Upon reporting, the school nurse who we contract with from the SJCOE will contact you to follow-up.
First and Last Name
Do you feel ill?
Do you have any of the following COVID-19 symptoms? (Mark all that apply)
Temperature of 100.4 degrees or higher
Shortness of breath or difficulty breathing (unexplained)
Cough (unexplained and unrelated to existing allergies or underlying chronic condition)
Runny nose or congestion (unexplained and unrelated to existing allergies or underlying chronic condition)
Chills or uncontrollable body shaking with chills
Headache, muscle aches, or body aches (unexplained)
New loss of taste or smell
Nausea or vomiting (unexplained)
Sore Throat (unexplained)
I have no COVID-19 symptoms
Have you been diagnosed with COVID-19 or asked by a health care provider to be tested for COVID-19 in the past 14 days?
Have you been in close contact (less than 6 feet for 15 minutes or more) with someone who has been diagnosed with COVID-19 or someone who has been told by a health care provider to be tested for COVID-19 in the past 14 days?
If you indicated YES to any of the above questions, stay home, contact your health care provider, notify the Superintendent, and follow established leave procedure. If you indicated NO to all of the above questions and do not have any COVID-19 symptoms, you may report to your worksite. All employees must follow SJC Public Health protocols for physical distancing and face coverings, and practice general safety precautions while the New Hope Elementary School District worksite. If you feel ill or exhibit COVID-19 symptoms at any time during your shift, please put your mask on, notify your supervisor, and go home. By submitting this form, you attest to the accuracy of the information provided.
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This form was created inside of San Joaquin County Office of Education.