Employee COVID-19 Self-Certification and Verification Form
In response to the COVID-19 pandemic and in order to ensure a safe and healthy environment for our school community, Joint guidance from the Illinois State Board of Education and the Illinois Department of Public Health requires that every employee undergo a daily symptom screening prior to entering any School District building. Employees will conduct this symptom screening on each day prior to their arrival for work and report consistent with the parameters outlined below. This form must be completed and submitted DAILY to St. Anne High School, until otherwise notified by the district.
Employee Name *
I conducted a daily symptom screening to determine if I exhibit any of the following COVID-19 symptoms: Temperature of 100.4 (or greater), Cough, Shortness of breath or difficulty breathing, Chills, Fatigue, Muscle and body aches, Headache, Sore Throat, New loss of taste or smell, Congestion or runny nose, Nausea and/or vomiting, Diarrhea, or Any other COVID-19 symptoms identified by the Center for Disease Control or the Illinois Department of Public Health. Choose one of the following statements.
Clear selection
Next
Never submit passwords through Google Forms.
This form was created inside of St. Anne Community High School #302. Report Abuse