subject_line
Daily Health Questionnaire
Today's Date
*
+
First & Last Name:
*
Email:
*
I am a(n):
*
Employee
Volunteer
FCS Parent/Guardian
Visitor
Department:
*
Church
School
Preschool
Ministry:
*
Communications
Foothill Kids
Guest Services
Foothill Students
Worship
Select the campus(es) you will be at today:
*
Baseline
Grand
Route 66
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.
*
I understand
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
*
Yes
No
Comments
Comments
Section 2: Social Distancing & Close Contact
Are you subject to a quarantine or isolation order?
*
Yes
No
Comments
Comments
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.
*
Yes
No
Comments
Comments
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).
*
Yes
No
Comments
Comments
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.
*
clear