COVID-19 Building Pre-Entry Screening Form

Date *

Building *

Choose the building you are reporting to in the dropdown below

Name *

First Last

Email *

After you complete the questionnaire you will receive an on-screen message and an emailed message. As you enter any District building you must present the on-screen message or the email message on your cellphone to be allowed in the building.

Enter Email Confirm Email

Department/Office *

Choose the department/office you report to in the dropdown below

School *

Choose the school you report to in the dropdown below

District Employee ID Number *

Please enter last 5 digits of your Employee ID

Phone *

In the past 24 hours, have you had one of the following symptoms unrelated to a pre-existing medical condition: frequent cough or shortness of breath? *

Yes
No

In the past 24 hours, have you had TWO of the following symptoms unrelated to a pre-existing medical condition: sore throat, chills, headache, muscle pain, new loss of taste or smell? *

Yes
No

In the past 24 hours, have you experienced a fever of 100.4℉ or above? *

Yes
No

Have you been in close contact with someone who tested positive for COVID-19 within the past 14 days but are not fully vaccinated? Close contact: Within six feet of a COVID positive person for a total of 15 minutes or more over a 24-hour period during the 48 hours before the positive person exhibited symptoms, or if asymptomatic, 48 hours before the COVID test was administered. Fully vaccinated: Received two doses of Pfizer or Moderna vaccine or one dose of Johnson & Johnson vaccine AND have reached the 14 day post-vaccination threshold. *

Yes
No

User Acknowledgement *

I acknowledge the terms below.

I understand the electronic submission of this form effectively serves as my signature and I certify that I have accurately completed the COVID-19 Building Pre-Screening Form and will comply with the outcomes identified above. I understand I may not enter at any District building if I answered YES to any of the questions above. I acknowledge the terms above and certify that I have completed the COVID-19 screening questions and will comply with the requirements identified.

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COVID-19 Building Pre-Entry Screening Form

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Office of Employee Health Services

COVID-19 Building Pre-Entry Screening Form

Office of
Employee Health Services