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Daily COVID-19 Questionnaire

STAFF:  Please complete this short questionnaire each morning before the start of school (between 5-7 a.m.) to allow time for your school to check questionnaire responses.

I am (check one box):*
Answer Required
If Special Services Staff, please indicate in which building(s) you will be working today.
Answer Required

SECTION 1:  Symptoms

If you exhibit one or more of the following symptoms, please stay home.

Do you have a NEW uncontrolled cough? *
(For persons with chronic allergic/asthmatic cough, a change in their cough from baseline.)
Answer Required
Do you have a sore throat?*
Answer Required
Do you have a new onset of severe headache, especially with fever?*
Answer Required
Are you experiencing diarrhea, vomiting, or abdominal pain?*
Answer Required
Do you have difficulty breathing or shortness of breath?*
Answer Required
Do you have a change in or a new loss in sense of taste or smell?*
Answer Required

SECTION 2:  Close Contact/Potential Exposure

If you answer 'Yes' to any of the following questions, please stay home.  Contact your health care provider or your local health department for further guidance.

Have you had close contact (within 6 feet for at least 10 minutes) with a person with a confirmed case of COVID-19 or with a person who is awaiting results of a COVID-19 test due to symptoms.*
Answer Required
Have you been diagnosed with COVID-19 within the last two weeks?*
Answer Required
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official in the last two weeks?*
Answer Required
Have you traveled to another state or U.S. Territory (i.e., U.S. Virgin Islands or Puerto Rico) beyond the immediate region (New York, Connecticut, Pennsylvania, and Delaware) in the past 10 days? *
Answer Required
Have you traveled to a country listed as a Level 2, 3, or 4 Risk on the CDC’s “COVID-19 Travel Recommendations by Destination” in the past 14 days? (See link below) *
Answer Required

CDC's "COVID-19 Travel Recommendations by Destination"

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