Visitor Health Check

Salk Middle School

First Name

Last Name

Phone

Email Address

Role

Parent

Company/Vendor

Volunteer

Substitute

Other

* The district reserves the right to manually screen any student or staff who appears ill in addition to this attestation. *

Do you currently have any of the above symptoms (not related to a known chronic health conditions like seasonal allergies)?

Symptoms Present?	Yes	No
Have you been in close contact (for example, within 6ft for greater than 15 minutes) with anyone with suspected or confirmed COVID-19 within the past 14 days?	Yes	No
Have you taken any medication to reduce a fever before coming to onsite?	Yes	No

Optional - Remember this computer?

Yes, I plan on using this computer in the future.