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.
Sign in to Google
to save your progress.
Please indicate your home school:
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.
Trouble breathing/Shortness of breath
Loss of taste or smell
Congestion (Not from allergies)
No symptoms at all
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:
Never submit passwords through Google Forms.
This form was created inside of Community High School District 218.