New Submission

Immediately upon arrival, you must complete this brief survey. At the end of the survey is a list of required guidelines that you must adhere to while on Cutler-Orosi Joint Unified School District property.

Antes de ingresar a cualquier instalación del distrito, debe completar esta breve encuesta. Al final de la encuesta hay una lista de pautas obligatorias que debe cumplir mientras se encuentre en la propiedad del Distrito Escolar de Cutler- Orosi .

Languagefield type radio button
LanguageEnglishSpanish
Type*field type radio button
TypeEmployeeSubstituteVisitor/Other
Employee*field type drop-down
Site*field type drop-down
First Name*field type single line
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Last Name*field type single line
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Questions / Pregunta

I self certify that I do not have a temperature at or above 100.4*field type radio button
I self certify that I do not have a temperature at or above 100.4TrueFalse
I do not have any of the following COVID-19 symptoms:*field type radio button
• Cough
• Shortness of breath or difficulty breathing
• Muscle/Body Aches
• New loss of taste or smell
I do not have any of the following COVID-19 symptoms:TrueFalse

Sympton Review*field type radio button
Sympton ReviewI have received clearance from a medical provider and/or have tested negative for COVID-19.I have NOT received clearance from a medical provider and/or have tested negative for COVID-19.

You have clicked false to one of the questions, if this is incorrect adjust your answer.

You are directed to contact your Site Administrator and to report to the Personnel Department.

You have clicked false to one of the questions, if this is incorrect, please adjust your answer.

Please continue to fill out this form and submit below.

After submission immediately leave the building.

If you are a district employee contact the Personnel Department at 559-528-4763 and your Administrator by phone or electronically and let them know you need to go home. Enter your absence on Frontline under Sick Leave, and consider consulting a medical professional.

EMPLOYEES:
- If you feel sick at work and/or exhibit symptoms of COVID-19 per CDC, immediately contact the Personnel Department and your Administrator by phone or electronically and let them know you need to go home. Enter your absence on Frontline under Sick Leave, and consider consulting a medical professional. Personnel Department will determine your leave entitlement.
- Remember to continue to enter your absences into Frontline and notify the Personnel Department regarding any changes in your status.

Si ingresa en las instalaciones de la escuela:
- Concuerdo en lavarme las manos con frecuencia o usar desinfectante de las manos, mantener el distanciamiento social, cubrirme al toser, estornudar en un pañuelo de papel y disponer del papel que utilice de inmediato, y evitare tocarme la cara.
- Mantendré la distancia social mientras interacciono con los demás.
- Solo entrare en las áreas que me corresponden
- No me reuniré en grupos mayores de 10 si no se puede mantener el distanciamiento .

Datefield type date
Date will be captured on form submission
Name*field type single line
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Job Title*field type single line
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Signature*field type signature

SubmissionTypefield type single line
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Secretaryfield type single line
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Employee IDfield type single line
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