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Health Screening
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Mandatory Health Screening Questions
for Students, Staff, Vendors
admin
User Role
Household
Name
*
First
Last
Date
Date Format: MM slash DD slash YYYY
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Health screening for...
*
Staff
Student
Vendor
Select Student
*
Select
Student ID
Student Grade
Student Name Full
Student Name
First
Last
Company
Staff Name
First
Last
Have you had COVID-19 symptoms in the past 14 days?
Fever or chills (100°F or greater)
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting and/or Diarrhea
Bloodshot eyes
Neck pain
Rash
No
Yes
How are you feeling?
*
Click on any of these COVID-19 symptoms you may have had within the
past 14 days
.
Fever or chills
(100°F or greater)
New uncontrolled
cough that causes
difficulty breathing
Sore Throat
New onset of severe
headache, especially
with a fever
Diarrhea, vomiting,
or abdominal pain
No Symptoms
Had close contact (within 6 feet of an infected person for at least 15 minutes) with a person with confirmed COVID-19?
*
No
Yes
Traveled to or lived in an area where the local, Tribal, territorial, or state health department is reporting large numbers of COVID-19 cases as described in the Community Mitigation Framework?
*
No
Yes
Link to Community Mitigation Framework
here
Live in areas of high community transmission (as described in the Community Mitigation Framework) while the school remains open?
*
No
Yes
Link to Community Mitigation Framework
here
Symptom Total
In School Temperature Check
Not taken
Normal
Has Tempature
