Tierra Linda School Staff COVID-19 Screening Form
All staff must complete this survey for EACH DAY that they come onto a school campus for any reason. Please note: This screening form will be shared with your site principals and secretaries so they can ensure everyone who comes on campus has completed the health screening. This is for everyone's safety. The privacy of your health information is important - we have intentionally kept this form vague so you are not required to report specific symptoms on this form.

IF YOU FEEL ILL, OR IF YOUR TEMPERATURE IS 99.9 F OR GREATER (99F using contactless thermometer), YOU MAY NOT GO ONTO A SCHOOL CAMPUS OR SCSD FACILITY.

If you will not be coming onsite as scheduled, please notify Cori Carpenter at ccarpenter@scsdk8.org and cc Kristen at kugrin@scsdk8.org and Nurse Terri at nurse@scsdk8.org.

You may be subject to isolation requirements. Please contact nurse Terri at tmotraghi@scsdk8.org for information on when you can return to work.

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Please note: This screening form will be shared with your site principals and secretaries so they can ensure everyone who comes on campus has completed the health screening. This is for everyone's safety. The privacy of your health information is important - we have intentionally kept this form vague so you are not required to report specific symptoms on this form.
First and Last Name *
Job Title *
People have reported a wide range of COVID-19 symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. These symptoms could include fever, chills, cough, shortness of breath or difficulty breathing, fatigue, headache, sore throat, loss of taste or smell, muscle pain, congestion or runny nose, nausea or vomiting, diarrhea. Individuals with one or more of these symptoms should consider COVID-19 testing.
I confirm that I took my temperature today before coming onsite. I confirm that I am NOT experiencing a temperature above 99.9 degrees Fahrenheit (Note: threshold is 99 degrees for contactless thermometers). *
Required
I confirm that I do NOT have the symptoms listed above OR that if I do have symptoms, they can be better explained by a pre-existing health condition for which I have recent medical documentation from the last 12 months. *
Required
I confirm that in the last 14 days I have not knowingly been in close contact (within <6 feet for >15 minutes) with someone who has COVID-19 or who is experiencing COVID-19 symptoms. *
Required
I acknowledge that if I DO have at least one of the symptoms above that is not better accounted for by a pre-existing healthcare condition, if I DO have a temperature above 99.9 degrees Fahrenheit or if I HAVE knowingly been in close contact with someone with COVID-19/COVID-19 symptoms in the last 14 days, I will not come to campus and am required to contact Nurse Terri at nurse@scsdk8.org. *
Required
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