Daily Health Self-Screening
Please complete this self-screening BEFORE you come to campus for any reason (short visit; part-time shift; or full shift).

If you answer NO to ALL of the questions below, you may come to campus and begin working.

If you answer YES to any of the following questions, please STAY HOME until you feel better and/or have consulted with a doctor/our school nursing services. Please also inform your supervisor and check with the MSA Human Resources (HR) department for further instruction.

Please remember to wash your hands frequently, practice safe social distancing, and wear masks when social distancing is not possible. Thank you.
Email address *
Your Name (First Name/Last Name) *
Your answer
Please use a thermometer to take your temperature and check for a fever before coming to work. Do you have a temperature/100.4 F or above (without fever-reducing medication such as Tylenol or ibuprofen)? *
Have you had any chills in the last 72 hours? *
Have you had a cough in the last 72 hours? *
Have you had a sore throat in the last 72 hours? *
Have you had any trouble breathing or experienced shortness of breath during the last 72 hours? *
Do you have any new muscle aches (within the past 72 hours)? *
Do you have a new headache (within the past 72 hours)? *
Do you have new loss of smell or taste (within the past 72 hours)? *
Are you feeling sick today or have you felt sick within the past 72 hours? *
Have you been in close and prolonged physical contact (within less than six feet for at least ten minutes) with an individual who has tested positive for or been diagnosed with COVID-19, or exposed to their cough or sneeze, within the last 14 calendar days; or have you tested positive for or been diagnosed with COVID-19 within the last 14 calendar days? *
Tennessen Notice: Prior to entering the office, all individuals will be asked a series of questions. This data is classified as private under the Minnesota Government Data Practices Act. We will use this data to screen individuals seeking admission to our campuses/buildings for potential health risks to try to avoid the potential of spreading contagious diseases. The data helps us to determine whether risk factors are present and whether you will be denied admission for the protection of agency staff and/or the public. This is not a COVID-19 test and is not a determination of whether or not an individual is infected with or has been exposed to COVID-19. This data will be gathered and reviewed by agency staff, including non-medical personnel, in deciding whether to permit you admission to the office. You are not legally required to provide this data and providing the data is voluntary. However, if you refuse to provide the data, you will not be admitted to the campuses or buildings. The data collected from you may be shared with agency staff collecting the data, agency HR staff, the agency safety administrator, agency management, and other persons or entities authorized by law. *
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