Self Screening Log
All employees must conduct a self-screening prior to coming to work each day.

Each employee must log/sign that they have conducted the self-screening and are free of symptoms outlined below.
Sign in to Google to save your progress. Learn more
Employee Name *
Date *
MM
/
DD
/
YYYY
Are you experiencing any symptoms such as current or recent fever (100.4 degrees or higher), new or worsening cough, new or worsening shortness of breath or respiratory illness, sudden lack of taste or smell, Sudden onset of unexplained gastrointestinal illness? *
Have you been in close contact with anyone who has been diagnosed with COVID-19? **CLOSE CONTACT is defined as: Being within approximately 6 feet of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case or having direct contact with infectious secretions of a COVID-19 case (being coughed on) *
Have you been in close contact with anyone who is experiencing symptoms of COVID-19, but has not yet been confirmed? *
Are you living with - or, in close contact with anyone (such as a family member) who is experiencing symptoms or has been confirmed as positive for COVID-19? *
Have you traveled outside of the continental United States within the past 14 days? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Le Grand Union High School District.

Does this form look suspicious? Report

Google Forms