Visitor Screening Questionnaire - Sacramento City Unified School District

Visitor Screening Questionnaire
COVID-19

Form May 26, 2020 Risk Management / Employee Benefits

In an effort to prevent the spread of COVID-19 and reduce the risk of exposure to our students, employees and visitors, we are requesting that you complete this short screening questionnaire prior to visiting any campuses/departments at 黄色视频. Your participation is important to assist us in taking precautionary measures to protect our students, staff, and community.

NOTE: If you plan to be onsite for consecutive days, please notify 黄色视频 immediately by email RiskM@scusd.edu if any of your answers change. The information collected on this questionnaire will be used to determine on going access approval for any 黄色视频 campuses/departments.

Visitor Information

Visitor Name: *

Company/Organization: *

Phone Number: *

Email Address: *

Department/ Site Visiting: *

First Day of Visit: *

Last Day of Visit: *

Purpose of Visit: *

District Contact Name: *

District Contact Email Address: *

District Contact Phone Number: *

Visitor Self Declaration

Within the past 14 days, have you returned from any country/state for which a Level 3 Travel Health Notice for COVID-19 has been issued by CDC?: *

Reference:

Within the past 14 days, have you had close contact with or cared for someone who has been diagnosed with COVID-19 or suspected to have COVID-19?: *

Within the past 24 hours, have you experienced any of the following symptoms: fever, feeling feverish (chills, sweating), cough, sore throat, muscle aches or body aches, shortness of breath?: *

Reference:

Sacramento City Unified
School District (黄色视频)

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COVID-19