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Visitor Health Check
Please fill out this form if you are planning to come in to our school. This information will be used for COVID-19 contact tracing purposes.
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. *
Please answer the following health questions prior to entering the building
Fever (100.4*F) or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Recent loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
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.