Employee Health Screening - Lake Bluff Park District

Department*

Select the department you work for.

Name*

First Last

Check the box of any symptoms you have experienced in the past 7 days.*

Check all that apply.

Persistent cough
Shortness of breath
Fever (above 100.4 F)
Repeated shaking/chills
Muscle Pain/Aches
Sore Throat
Loss of Taste/Smell
Vomiting, Diarrhea
None

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).*

Yes
No

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?*

Yes
No

Have you recently (in the past 14 days) visited an area where there has been a significant outbreak of COVID-19 activity?*

Yes
No

Consent*

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.