Employee Health Screening
Please complete this form before visiting the Park District.
Select the department you work for.
Check the box of any symptoms you have experienced in the past 7 days.
Check all that apply.
Shortness of breath
Fever (above 100.4 F)
Loss of Taste/Smell
Have you recently (in the past 14 days) been in close contact with anyone who has exhibited any of the above symptoms? (Close contact means within less than six feet for a prolonged period of time).
Have you recently (in the past 14 days) been in contact with someone who has tested positive for COVID-19 or been advised to self-isolate by a medical professional due to COVID-19 reasons?
Have you recently (in the past 14 days) visited an area where there has been a significant outbreak of COVID-19 activity?
I agree that checking this box will serve as my digital signature and that I accept the terms below.
These responses are accurate to the best of my knowledge. I agree to follow the instructions provided to me by the Lake Bluff Park District. If I believe that my symptoms are related to a separate condition, I will seek documentation from my physician and provide it to Tina Brewer, Human Resources.