UA COVID-19 Self Screening Questionnaire

All staﬀ are required to conduct a daily self-screener, including checking your temperature before reporting for onsite work. Employees are required to report results according to established procedures electronically.

Date*

Date

Name*

First NameLast Name

Campus*

Daily Temperature*

Department/Grade*

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Cough
Shortness of breath or difficulty breathing
Repeated shaking with chills
Muscle pain
Headache
Sore throat
Loss of taste or smell
Diarrhea
Feeling feverish or a measured temperature greater than or equal to 100 degrees Fahrenheit

If you answered yes to ALL of the below, you are required to:

Immediately Notify Human Resources
Provide the OFFICIAL documentation and remain oﬀ campus until cleared to return
Provide Human Resources with health status updates
- It is also recommended that you consult with your healthcare provider.

Reminders to follow if you are cleared to return:

Wear a mask or face covering
Wash your hands or use hand sanitizer regularly
Practice social distancing of at least 6 feet
Notify Human Resources if you have traveled outside the area in the last 14 days

2) In the last 14 days have you:*

	Yes	No
In the past 14 days, have you had close contact (without a mask, less than 6 feet apart, & for more than 15 minutes) with a lab-conﬁrmed positive (not a rapid test) COVID-19 person?

In the past 14 days, have you had close contact (without a mask, less than 6 feet apart, & for more than 15 minutes) with a lab-conﬁrmed positive (not a rapid test) COVID-19 person?*

YesNo

Date of someone you came in close contact with symptoms:

Date

Are you experiencing symptoms that you believe NOT TO BE a common illness but could very likely be COVID-19?*

YesNo

Do you understand that if you are sick you must submit PTO via TCP and will not be permitted to work remotely?*

YesNo

If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.

Universal Academy will not allow school employees to return to the school until:

In the case of an individual who was diagnosed with COVID-19, the individual may visit when all three of the following criteria are met: at least 24 hours have passed since resolution of fever without the use of fever-reducing medications; and the individual has improvement in respiratory symptoms (e.g., cough, shortness of breath); and at least 10 days have passed since symptoms first appeared; or o In the case of an individual who has symptoms that could be COVID-19 and does not get evaluated by a medical professional or tested for COVID-19, the individual is 2 assumed to have COVID-19, and the individual may not return to work until the individual has completed the same three-step criteria listed above; or o If the individual has symptoms that could be COVID-19 and wants to return to work before completing the above self-isolation period, the individual must obtain a medical professional’s note clearing the individual for return based on an alternative diagnosis.
Do not allow an individual with known close contact to a person who is lab-confirmed to have COVID-19 to return to work until the end of the 14-day self-quarantine period from the last date of exposure.
Schools must clean and sanitize bathrooms, doorknobs, and other commonly touched surface.

If you are taking sick time that extends beyond 3+ consecutive days, you will be required to have a medical release prior to returning to work. If you are sick you will not be permitted to work remotely.

IMPORTANT NOTICE

The Emergency Paid Sick Leave (EPSL) that covers up to 80 work hours for employees that are out due to COVID-19 will end December 31, 2020. Starting January 1, 2021, any COVID-19 related time oﬀ will no longer be covered. You would be required to use your available PTO or unpaid time oﬀ during your 14-day self-quarantine period. You will be notiﬁed if the FFCRA is revised by Congress.

I certify to the best of my knowledge; this information is accurate.

Signature*

Many symptoms of COVID-19 are also present in common illnesses

Symptoms of COVID-19	Strep Throat	Common Cold	Flu	Asthma	Seasonal Allergies
Fever or chills	X		X
Cough		X	X	X	X
Sore throat	X	X	X		X
Shortness of breath Or Difficulty breathing				X
Fatigue		X	X	X	X
Nausea or Vomiting	X		X
Diarrhea	X		X
Congestion or Runny Nose		X	X		X
Muscle or body aches	X	X	X

Note: The table above does not include all COVID-19 symptoms

Employee COVID-19 Self Screening Questionnaire