Impossible d'ouvrir ce fichier car JavaScript n'est pas activé dans votre navigateur. Activez-le, puis rechargez la page.
COVID Test Screening Form
This form needs to be completed before testing.
Connectez-vous à Google
pour enregistrer votre progression.
En savoir plus
* Indique une question obligatoire
What campus are you on?
*
Eastside Elementary
Thomas C Brunson Elementary
Warren Middle School
Warren High School
SEACBEC
ABC
District Employee
First Name
*
Votre réponse
Last Name
*
Votre réponse
Date of Birth
*
JJ
/
MM
/
YYYY
Gender
*
Male
Female
Unknown
Phone Number
*
Votre réponse
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unknown
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Street Address
*
Votre réponse
City
*
Votre réponse
State
*
Votre réponse
Zip
*
Votre réponse
County
*
Votre réponse
Do you have Fever
*
No
Yes
Do you have Chills
*
No
Yes
Experiencing Rigors (a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever)
*
No
Yes
Myalgia (Muscle pain or ache)
*
No
Yes
Headache
*
No
Yes
Sore Throat
*
No
Yes
Loss of taste
*
No
Yes
Loss of Smell
*
No
Yes
Cough
*
No
Yes
Difficulty Breathing
*
No
Yes
Shortness of Breath
*
No
Yes
Nausea
*
No
Yes
Diarrhea
*
No
Yes
Fatigue
*
No
Yes
Congestion
*
No
Yes
No symptoms
*
No
Yes
Clinically diagnosed with pneumonia
*
No
Yes
Diagnosed with Acute Respiratory Distress Syndrome (ARDS)
*
No
Yes
None
*
Yes
No
Have you been in close contact with a confirmed or Probable case of COVID-19 in the past 14 days?
*
No
Yes
If yes, what is the Confirmed or Probable Case Name?
Votre réponse
Have you tested positive in the past 90 days?
*
Yes
No
Envoyer
Effacer le formulaire
N'envoyez jamais de mots de passe via Google Forms.
Ce formulaire a été créé dans Warren School District.
Signaler un cas d'utilisation abusive
Forms
