Daily Health Questionnaire

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Select the campus(es) you will be at today: *
By completing & submitting this form I understand that if any of the following symptoms first appeared within the last 10 days I should NOT complete this form or volunteer today at Foothill Church or Foothill Christian School.

- Have an elevated body temp (greater than or equal to 100.4°F or 38°C)
- Shortness of breath
- Fever or chills
- Cough
- Shortness of breath or trouble breathing
- Feeling tired
- Muscle or body aches
- Headaches
- Sore throat
- Nausea or vomitting 
- Diarrhea
- Congestion or runny nose
- New loss of taste or smell


By completing this form I understand that if I have had contact with a person known to be infected with the Novel Coronavirus (COVID-19) within the last 10 days I should NOT complete this form or volunteer today at Foothill Church or Foothill Christian School. *

Section 1: Employee Health & Wellness Checklist

Are you experiencing any of the following symptoms or combination of symptoms within the last 10 days? If so, please select "yes" and explain more in the comment section below.

- Have an elevated body temp (greater than or equal to 100.4°F or 38°C)
- Shortness of breath
- Fever or chills
- Cough
- Shortness of breath or trouble breathing
- Feeling tired
- Muscle or body aches
- Headaches
- Sore throat
- Nausea or vomitting 
- Diarrhea
- Congestion or runny nose
- New loss of taste or smell
 *
 

Section 2: Social Distancing & Close Contact

Are you subject to a quarantine or isolation order? *
 
Have you been exposed to anyone who has tested positive for COVID-19 in the last 10 days? If so, please mark “yes”  and add a comment. *
 
Are you fully vaccinated against Covid-19?

NOTE: People are considered “fully vaccinated” against COVID-19 two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna) or two weeks after they have received a single-dose vaccine (Johnson and Johnson (J&J)/Janssen). *
 
I understand that if I have answered "YES" to section 1, or if I have been exposed to Covid-19 and am not fully vaccinated then I may NOT enter the premises without approval from my supervisor. I also acknowledge that answering untruthfully may result in disciplinary actions. *
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