Visitor Health Check

Salk Middle School

First Name

Last Name

Phone

Email Address

Role

Parent

Company/Vendor

Volunteer

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 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.