COVID – 19 EMPLOYEE SYMPTOM QUESTIONNAIRE - MONTGOMERY MIDDLE

Please complete this questionnaire online at home OR print the form provided to you during training, and bring to your District place of work each time you come on campus. If you do not have a printer at home to generate this page, jot your answers down on a piece of paper and bring to work instead. If questions, please call Nursing and Wellness Office. 619-725-5501.

If you respond “Yes” to any of these questions or if your temperature is >100oF (or >37.8oC),
please: (a) do not come to work today, and (b) call your supervisor to explain the reason.
If you responded “No” to all these questions and your temperature is normal, bring this form
with you to work today.

NOTE FROM MONTGOMERY: PPE station is located in the hallway, outside room 110. AS NEEDED, please take a pair of gloves, shield, and mask. There are two boxed thermometers, ready to use. Please wipe them off with paper towel which you will spray with sanitizer. Gloves and masks, if taken, are not reusable. Shield may be cleaned and kept in your classroom-please DO NOT return to the station. Any questions, please notify the custodial staff.
Email address *
1. Do you have a new cough that you cannot attribute to another health condition? *
2. Do you have shortness of breath that you cannot attribute to another health condition? *
3. Do you have headache that you cannot attribute to another health condition? *
4. Do you have a runny nose or congestion that you cannot attribute to another health condition? *
5. Do you have any of the following symptoms: fever, chills, repeated shaking with chills, muscle pain, sore throat, nausea, vomiting, diarrhea or new loss of taste or smell? *
6. Have you come into close contact (within 6 feet) with someone who has a laboratory-confirmed COVID-19 diagnosis in the past 14 days? *
7. Has a health care provider or public health official asked you to quarantine (i.e., stay home) during this period? *
8. Have you traveled to a foreign country in the past 14 days? (Respond “No” if your only travel is commuting to work from Mexico’s border region with San Diego) *
9. Print Name (or employee number only for privacy) *
10. Date *
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