Health Screening Questionnaire
Please complete the following form to be provided access to the building each day. This is only shared with the Human Resources Director. The point of this to try to keep employees safe. The questions are based on unusual symptoms in regards to COVID-19.
Name *
Your answer
School District Email Address: *
Your answer
Work Location *
1 - I have one or more symptoms causing me to feel unwell. Symptoms may include, but are not limited to: headache, fatigue/feeling tired, muscle aches, sore throat, cough, sneezing, fever, shortness of breath, recent loss of taste and smell, other respiratory symptoms or chills. (unusual symptoms) *
#2 - I live in a household with someone who has symptoms as outlined in #1 causing them to feel unwell. (unusual symptoms) *
I answered no to #1 and #2 but I (or a member present in my household) did have symptoms within the last 72 hours. *
I have traveled (hotel, airplane, etc.) outside of NH in the last 14 days. *
I have had contact with an individual who has tested positive for COVID-19 within the last 14 calendar days. *
I have had contact with an individual who is experiencing virus symptoms such as those indicated in #1, but has not been tested, within the last 14 calendar days. *
I have been involved in other activities that put me at a greater risk to come in contact with COVID-19 *
I have taken my temperature today and it is over 100.0 degrees Fahrenheit *
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