AMHS COVID-19 HEALTH SCREEN ATTESTATION
Name
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Your Role at AMHS
Student
Employee
Parent
Visitor
Symptoms of Covid-19
Cough
Fever (above 100.04 ) or chills (before taking any medication to reduce the fever)
Shortness of breath or difficulty breathing
Unusual Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Have you had any of the SYMPTOMS OF COVID-19 above that are not attributable to another condition?
Yes
No
What is your temperature?
Between 97 and 100.04 degrees F
Above 100.04 degrees F
Within the past 14 days, have you had close contact with anyone that you know who had COVID-19 or COVID-19 like symptoms? Close contact is defined as being within 6 feet for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on), or the person lives in your household.
Yes
No
Have you had a positive COVID-19 test for active virus in the past 10 days?
Yes
No
Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?
Yes
No
Submit
Should be Empty: