COVID Test Screening Form
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* Required
What campus are you on?
*
Eastside Elementary
Thomas C Brunson Elementary
Warren Middle School
Warren High School
SEACBEC
ABC
District Employee
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Unknown
Phone Number
*
Your answer
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unknown
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
County
*
Your answer
Do you have Fever
*
No
Yes
Do you have Chills
*
No
Yes
Experiencing Rigors (a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever)
*
No
Yes
Myalgia (Muscle pain or ache)
*
No
Yes
Headache
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No
Yes
Sore Throat
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No
Yes
Loss of taste
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No
Yes
Loss of Smell
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No
Yes
Cough
*
No
Yes
Difficulty Breathing
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No
Yes
Shortness of Breath
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No
Yes
Nausea
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No
Yes
Diarrhea
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No
Yes
Fatigue
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No
Yes
Congestion
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No
Yes
No symptoms
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No
Yes
Clinically diagnosed with pneumonia
*
No
Yes
Diagnosed with Acute Respiratory Distress Syndrome (ARDS)
*
No
Yes
None
*
Yes
No
Have you been in close contact with a confirmed or Probable case of COVID-19 in the past 14 days?
*
No
Yes
If yes, what is the Confirmed or Probable Case Name?
Your answer
Have you tested positive in the past 90 days?
*
Yes
No
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