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Daily COVID-19 Staff Questionnaire.Wilson

STAFF: Please complete this short questionnaire each morning before the start of school (between 5-8 a.m.) to allow time for your school to check questionnaire responses. You must continue to take your temperature each morning.

LAST NAME: *

Answer Required

FIRST NAME: *

Answer Required

SECTION 1: Symptoms (Check ONE)*

Answer Required

I attest that I am NOT exhibiting any of the symptoms listed below.

I am exhibiting at least one of the symptoms listed below. (Please stay home and contact your school nurse for further instruction.)

A fever of 100.0 F or above
A new cough (For persons with chronic allergic/asthmatic cough, a change in their cough from baseline)
A sore throat
A new onset of severe headache, especially with fever
Diarrhea, vomiting, or abdominal pain
Difficulty breathing or shortness of breath
Change in or new loss in sense of taste or smell

SECTION 2: Close Contact/Potential Exposure (Check ONE)*

Answer Required

I attest that I have NOT had close contact or been diagnosed as defined below OR I have been fully vaccinated. (You are considered fully vaccinated two weeks after receiving the last recommended dose of the vaccine.)

I have had close contact or been diagnosed as defined below. (Please stay home and contact your school nurse for further instruction.)

Close contact (within 6 feet for a cumulative 15 minutes over a 24-hour period) with a person with a confirmed case of COVID-19 or with a person who is awaiting result of a COVID-19 test due to symptoms; or
Been diagnosed with COVID-19 within 10 days; or
Been asked to quarantine by a medical professional or local public health official in the last two weeks.

SECTION 3: Travel (Check ONE and contact your school nurse with any questions)*

Answer Required

I attest that I have fully read and have complied/will comply with domestic and international travel guidelines outlined by the New Jersey Department of Health and the Centers for Disease Control and Prevention (CDC). See links below.

I have traveled and have not met the travel restrictions. I understand that I must notify my school and follow the quarantine/self-isolation guidelines as outlined by the NJDOH and CDC.

I verify that all information on this form is correct to the best of my knowledge.*

Answer Required

Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

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