Jennings School District COVID-19 Employee, Volunteer, Student Daily Self Screening Form
Please complete daily before your scheduled shift.

The screening protocol outlined below is based on the following:

● A review of screening protocols from multiple agencies
● Recommendations by the Centers for Disease Control and Prevention
● A literature review of the most common signs and symptoms of COVID-19
Questionnaire:

“YES or “No”, since your last day of work/school, or since your last visit to this facility, have you had any of the following questions. If you answered YES to ANY of these questions, do not report to work and immediately contact your direct supervisor or administrator/principal.
Email *
Employee Name *
If you are an Employee, Student or Volunteer, please enter your full name here.
Building/Department *
At what Building do you attend school or what building are you assigned to/working with at the Jennings School District?
Building/Department Administrator *
Building you will enter today *
Required
Date
MM
/
DD
/
YYYY
A new fever (100.4⁰ F or higher), or a sense of having a fever? *
Required
A new cough that you cannot attribute to another health condition? *
Required
New shortness of breath that you cannot attribute to another health condition? Have you lost any sense of smell or taste? *
Required
A new sore throat that you cannot attribute to another health condition? *
Required
New muscle aches (myalgias) that you cannot attribute to another health condition or that may have been caused by a specific activity(such as physical exercise)? *
Required
Have you had any close contact with a person that has a suspected or confirmed case of COVID-19 or demonstrated any of the above symptoms? *
Required
Are you experiencing chills or shaking with chills? *
Required
Are you experiencing headaches? *
Required
Are you experiencing a new loss of taste or smell? *
Required
I agree that if I become symptomatic, I will notify the organization, immediately. Electronically sign in the space below. *
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