COVID-19 Workplace Health Screening Form
Self Assessment for ALL people to fill out before or upon arriving at the building.
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Last Name: *
First Name: *
Affiliation with Mason Public Schools *
Building (Select all that apply) *
Required
In the last 24 hours, have you experienced any of the following? *
Yes
No
New or Worsening Cough
Shortness of Breath/Difficulty Breathing
New loss of taste or smell
Fever (100.4 or Higher) or felt feverish:
Actual temperature reading (fever is a temperature of 100.4 degrees F or higher). *
NOW REQUIRED
If you answered "Yes" to one or more the first four symptoms above, DO NOT GO INTO WORK. Self-isolate at home and CONTACT YOUR PRIMARY CARE PHYSICIAN'S OFFICE OR NEAREST URGENT CARE FACILITY for direction. Contact your supervisor for further direction. You should isolate at home for a minimum of 10 days since symptoms first appeared. You must also have 3 days without fevers and improvement in respiratory symptoms. MEDICAL DOCUMENTATION OF A CONDITION NOT RELATED TO COVID CAN RELEASE AN INDIVIDUAL FROM ISOLATION.
YOU WILL NEED EMAIL OR CALL RICK BROOKS BEFORE RETURNING TO WORK. brooksr@masonk12.net (517) 676-6534.
In the last 24 hours, have you experienced any of the following? *
Yes
No
Chills:
Muscle Aches:
Headaches:
Sore Throat:
Diarrhea:
Nausea or vomiting:
Congestion or runny nose:
If you answered "Yes" to two (2) or more of the seven symptoms above, DO NOT GO INTO WORK. Self-isolate at home and CONTACT YOUR PRIMARY CARE PHYSICIAN'S OFFICE OR NEAREST URGENT CARE FACILITY for direction. Contact your supervisor. You should isolate at home for a minimum of 10 days since symptoms first appeared. You must also have 3 days without fevers and improvement in respiratory symptoms. MEDICAL DOCUMENTATION OF A CONDITION NOT RELATED TO COVID CAN RELEASE AN INDIVIDUAL FROM ISOLATION.
YOU WILL NEED EMAIL OR CALL RICK BROOKS BEFORE RETURNING TO WORK. brooksr@masonk12.net
In the past 14 days, have you Been in close contact or cared for someone who has tested positive for CoVid-19: *
A close contact is determined by being in a room without a mask or being in a room with a mask and closer than 6 feet for a total of 15 minutes.
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