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I’m a non-DOE Staff/Contracted Provider
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School or Facility You're Entering
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Fill Out Daily Screening
Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath that started in the past 10 days?
Yes, and I have received a lab-confirmed negative result from a COVID-19 diagnostic test (not a blood test) since the onset of symptoms AND have not had symptoms for at least 24 hours.
Yes, and I am not in the category above.
In the past 10 days, have you gotten a lab-confirmed positive result from a COVID-19 diagnostic test (not a blood test) that was your first positive result OR was AFTER 90 days from your previous
Please note that 10 days is measured from the day you were tested, not from the day when you got the test result.
Are you considered fully vaccinated against COVID-19 by CDC guidelines OR were you recently (within the past three months) diagnosed with COVID-19 and finished isolation in the
past 90 days?
Please note that to be considered fully vaccinated by CDC guidelines, two weeks must have passed since you received the second dose in a two-dose series or two weeks must have passed since you received a single-dose vaccine.
No, I am not considered fully vaccinated or was not diagnosed with COVID-19 in the past 90 days.
Yes, I am considered fully vaccinated or was diagnosed with COVID-19 and finished isolation in the past 90 days.
To the best of your knowledge, in the past 10 days, have you been in close contact (within 6 feet for at least 10 minutes over a 24 hour period) with anyone who is currently diagnosed with COVID-19 or who has been told they have symptoms of COVID-19? Clinical staff who were in appropriate personal protective equipment (PPE) are not considered close contacts in these scenarios.
This Health Screening is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a medical condition. Health screening results will be reviewed for the sole purpose of gaining access to facilities and confidentiality will be maintained.
COVID-19 Testing Consent
As part of our efforts to keep schools safe, we are testing randomly selected students, staff and guests in schools for COVID-19. In order for us to administer a COVID-19 test to you, we need your consent. Please review our webpage on
COVID-19 Testing for Students and Staff
before submitting your consent.
Do you consent that a COVID-19 test can be administered to you?
Download a printable version of this questionnaire