Visitor Health Check

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. *

Please answer the following health questions prior to entering the building

Do you have any of the symptoms listed above within the last day that are not caused by another condition?	Yes	No
Have you been in close contact with anyone with confirmed COVID-19 (for example, within 6ft for greater than 15 minutes) within the past 14 days?	Yes	No
Have you had a positive COVID-19 test for active virus in the past 10 days, or are you awaiting results of a COVID-19 test?	Yes	No
Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?	Yes	No

Optional - Remember this computer?

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