COVID Test Screening Form
This form needs to be completed before testing.
What campus are you on? *
Staff First Name *
Staff Last Name *
Staff Date of Birth *
MM
/
DD
/
YYYY
Staff Gender *
Staff Phone Number *
Staff Race *
Staff Ethnicity *
Staff Street Address *
Staff City *
Staff State *
Staff Zip *
Staff County *
Do you have Fever *
Do you have Chills *
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) *
Myalgia (Muscle pain or ache) *
Headache *
Sore Throat *
Loss of taste *
Loss of Smell *
Cough *
Difficulty Breathing *
Shortness of Breath *
Nausea *
Diarrhea *
Fatigue *
Congestion *
No symptoms *
Clinically diagnosed with pneumonia *
Diagnosed with Acute Respiratory Distress Syndrome (ARDS) *
None *
Have you been in close contact with a confirmed or Probable case of COVID-19 in the past 14 days? *
If yes, what is the Confirmed or Probable Case Name?
Have you tested positive in the past 90 days? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Warren School District. Report Abuse