GSLA Self-Certification Form
All students, staff, volunteers, and other individuals must complete this form each day before entering the school building. Parents who are just dropping off their children at school do not need to complete this form.
First and Last Name *
Evaluation Questions:
1. Have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional in the past 10 days? *
2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 10 days? *
3. Have you had close contact with or cared for someone with symptoms related to COVID-19 within the last 10 days? *
4. Have you experienced any of these COVID-related symptoms in the last 10 days (to include: Fever (100.4°F or higher), new onset of moderate to severe headache, shortness of breath, new cough, sore throat, vomiting, diarrhea, abdominal pain from unknown cause, new congestion/runny nose, new loss of sense of taste or smell, nausea, fatigue from unknown cause, muscle or body aches. )? *
If you selected "NO" for all of your answers, you are ALLOWED TO ENTER THE SCHOOL BUILDING.
If you selected "YES" for one or more of your answers, you are NOT allowed to enter the school building.
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