Please choose the school or office where you are assigned. *
Required
First Name *
Your answer
Last Name *
Your answer
Temperature *
Your answer
Do you have any of these symptoms that are new, unexpected, or that you cannot attribute to another condition? (Please check off all that apply.) *
Required
Have you had close contact (within 6 feet for at least 15 minutes or greater within a 24 hour period) with someone who has tested positive for COVID-19 in the past 14 days? *
Within the past 14 days, have you traveled to an area subject to a Level 3 CDC Travel Health Notice or to a U.S. state with significant COVID-19 spread, as identified by the NJ Department of Health? *
Are you under evaluation for COVID-19 (waiting for results of a viral test to confirm infection)? *
Have you been diagnosed with COVID-19 and not yet cleared to discontinue isolation? *
Please read the statement below.
If you've answered yes to any questions, stay home, notify your supervisor and school nurse, and consult with your health care provider. Thank you!
A copy of your responses will be emailed to the address you provided.