COVID Screening – ZANDU HEALTH INITIATIVE

Zandu Health Initiative is working together with Minnesota Department of Education, Minnesota Office of Higher Education and the Minnesota Department of Health to keep you safe from COVID-19.

Staff and visitors must self-screen for COVID-19 symptoms before entering CDC facilities using the self-screening tool below on their mobile device. False statement on this form could be subject to an adverse personnel action, up to and including termination of your education plan.

Please complete the form below:

Remind student to:

1a. wash their hands or use hand sanitizer throughout their time in the building

1b. wear a mask at all times while in the classroom and lab

Date

1. Did you wash their hands or use alcohol-based hand rub (ABHR) on entry?(Required)

2. Temperature recording today(Required)

3. Have you had a fever of 100.4 or higher during the past week?(Required)

4. Which of the following respiratory symptoms have you had within the last 14 days?(Required)

Fever or feeling feverish?

Chills?

A new cough?

Shortness of breath?

A new sore throat?

New muscle aches?

New headache?

New loss of smell or taste?

None

5. I agree to

wash my hands or use hand sanitizer throughout my time in the building.

not shake hands with ungloved hands ungloved students during my time in class.

use a face shield at all times during the duration of the class.

follow infection control protocols and voluntarily assume all risks related to exposure to COVID-19.

First Name(Required)

Last Name(Required)

Phone Number(Required)

ZANDU HEALTH INITIATIVE

ZANDU HEALTH INITIATIVE

COVID-19 Onsite Form

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