KCKPS Employee Screening



Employee Number:
Last 4 digits of social security number:
Date:

Have you experienced any of the COVID-19 symptoms listed below within the last 48 hours?
In the last 48 hours, have you experienced any of the COVID-19 symptoms listed below?
Fever Cough
Shortness of breath Sore throat
Congestion Runny nose
Headache Chills
Body ache Fatigue
Loss of smell or taste Nausea/vomiting
Diarrhea    

The following questions apply to the last 14 days:
In the last 14 days,
have you been in close contact with a person who has symptoms of respiratory illness?
have you been in close contact with a person who has been confirmed positive with COVID-19?
have you been in close contact with a person who is in quarantine due to potential exposure?
have you been in close contact with a person who is awaiting test results for COVID-19?
have you traveled out of the United States or to a state or area for which a travel advisory has been issued?

If you answered YES to any of the questions above, and your symptoms are NOT due to a pre-existing medical condition, do not enter the building. Please return to your vehicle and contact your principal or supervisor for additional guidance.
I certify that all answers are true and correct to the best of my knowledge and I certify that I will follow the State of Kansas mandate and Kansas City Kansas Public Schools COVID-19 employee policy, which includes wearing a face covering or mask that covers my nose and mouth.

Signature:

  


These guidelines were developed based on the ReStart Wyco Road to Recovery Guidance Document and the recommendations provided by the Unified Government Public Health Department, KDHE, and the CDC. They are not intended to replace or to substitute for the advice of a healthcare provider. Revised 7/1/2020 em