Lake Forest South Elementary School Staff and Visitor Screening Questionnaire
To protect the public against the spread of COVID-19, Governor John Carney and Delaware Division of Public Health are REQUIRING that schools screen employees and visitors each day when they enter the building using the following questionnaire:
Please remember to continue following preventative measures while in the building:
- Wear a Mask
- Social Distancing
- Go Home When Sick
- Use Cough and Sneeze Etiquette
- Practice Hand Hygiene As Often and Thorough As Possible
- Clean High-Touch Surfaces In Your Area Regularly
* Required
Name:
*
Your answer
1. In the past 10 days, have you been near (within 6 feet for at least 15 minutes) a person who has a lab-confirmed case of COVID-19, or have you had direct contact with their mucus or saliva?
*
Yes
No
2. In the last 48 hours, have you had any of the following symptoms?
Fever of 100.4 F or above (or symptoms like alternating shivering and sweating)
*
Yes
No
New cough
*
Yes
No
New trouble breathing, shortness of breath or severe wheezing
*
Yes
No
New chills or shaking with chills
*
Yes
No
New muscle aches
*
Yes
No
Sore throat
*
Yes
No
Vomiting or diarrhea
*
Yes
No
New loss of smell or taste, or a change in taste
*
Yes
No
Nausea
*
Yes
No
Fatigue
*
Yes
No
Headache, congestion or runny nose with no other known cause (such as allergies)
*
Yes
No
3. If you answered 'Yes' to any of the symptoms above, do they have a known cause (i.e. asthma, COPD, sinusitis, allergies, etc.)?
*
Yes
No
Not Applicable
If you answered "Yes" to either question one or two and the symptoms do not have a known cause as identified in question three, you need to NOT report to work today or enter the building, and contact your doctor. Please notify you supervisor immediately and keep him/her informed of your progress while self-isolating and prior to determining a date for return to work.
Submit
Never submit passwords through Google Forms.
This form was created inside of Lake Forest School District.
Report Abuse
Forms
