Workplace Health Assessment
Coronavirus Disease (COVID-19)
* Required
Name
*
Your answer
Location (check any that apply)
All
Elementary
MS
HS
Maintenance
Transportation
Current Temperature, if your temperature is 100.4 or higher, please do not go into work and contact your supervisor.
*
Your answer
In the past 24 hours, have you experienced any of the following. If you check any of these boxes, please contact your supervisor.
Subjective fever (felt feverish or chills):
New or worsening cough
Shortness of breath
In the past 24 hours have you experienced any of the following. If you check two or more of these boxes, please contact your supervisor.
Sore Throat
Chills
Headache
Loss of taste or smell
Runny nose or congestion
Muscle aches
Abdominal pain
Fatigue
Nausea
Vomiting
Diarrhea
In the past 14 days, have you:
Had close contact with an individual diagnosed with COVID-19
If you answer YES to having close contact with an individual diagnosed with COVID-19, please do not go into work. Self-quarantine at home for 14 days and contact your primary care physician’s office. If you are given a probable diagnosis or test positive call your local health department to ensure they are aware.
Your answer
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