COVID 19 SCREENING
Student, Faculty and Staff Screening form
Email address *
Last Name of Student, Teacher or Staff *
First Name of Student, Teacher or Staff *
Identify yourself *
Required
School/Program attended *
Required
If Elementary, please indicate grade level. *
Required
If Elementary, please indicate Teacher.
1. Have you had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine? *
2. Have you traveled outside of NJ in the last 14 days? *
3. Since you were last at school, have you been diagnosed with COVID-19? *
4. Since you were last at school, have you had any of these symptoms? *
Required
Temperature Reading Prior to Arrival *
Submit
Never submit passwords through Google Forms.
This form was created inside of New Milford Board of Education. Report Abuse