CHSD 218 COVID-19 Staff Self Certification
This health screening form must be completed prior to the start of the work day at 7:30am. Each day staff will be asked to respond to these questions. If you are feeling sick or exhibiting symptoms, please stay home and call your school.
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Please indicate your home school: *
Last Name *
First Name *
Have you had signs of a fever or measured temperature greater than 100.4 degrees in last 24 hours? *
Please indicate if you have had any of the following symptoms in the last 24 hours. *
Have you been exposed to or been in "close contact" with an individual diagnosed with COVID-19? *
Have you, for any reason, been asked to self-isolate or quarantine by doctor, local public health official, or based upon IDPH or CDC guidelines? *
Signature - I acknowledge that the above is true and any false information may lead to public health concerns. (Please type your name) SIGNED: *
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