Health Check Before Work For Staff

First Name*

Last Name *

Department *

Check here if you are a Trustee or public/vendor

Are you feeling well today? *

Yes

No

Since your last day of work, or last visit here, have YOU had any of these symptoms? *

Fever or chills
Cough (not due to allergies)
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose(not due to allergies)
Nausea or vomiting
Diarrhea

Yes

No

Since your last day of work or last visit here, has someone in your home or someone you have had close contact with (within 6 feet for more than 10 minutes), exhibited any of these symptoms: *

Fever or chills
Cough (not due to allergies)
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose(not due to allergies)
Nausea or vomiting
Diarrhea

Yes

No

In the last 30 days, have you, someone in your home, or someone you have had close contact with (within 6 feet for more than 10 minutes) tested positive for COVID-19? *

Yes

No

You answered "YES". Do not enter the facility, proceed to your vehicle, and contact your supervisor and/or HR (Tina Pacific - 949-246-7453) for additional instructions. Please click the 'Submit' button.