1205-0548 Attachment A + B Symptom Tracker and Emotional Wellness Form 2-23-2022

Attachment A: Job Corps COVID-19 Symptom Tracker and Attestation

NOTE: Job Corps requires that students complete a COVID-19 Symptom Tracker and

Attestation every day when they are on center.

Name:

Student ID Number:

Email:

Date:

AM/PM:

Do you currently have any symptoms of COVID-19 (fever of greater than 100.4 degrees F or feeling feverish (chills, sweating, new cough, difficulty breathing, sore throat, muscle aches or body aches, vomiting or diarrhea, new loss of taste or smell)?

􀁸 Yes, I currently have one or more COVID-19 symptoms.*

􀁸 No, I do not have any symptoms of COVID-19.

Have you had close contact with a person who has a diagnosed or suspected case of COVID-19 in the last 14 days?

􀁸 Yes*

􀁸 No

By checking this box, I attest that the answers to these questions are true. (Checkbox)

*If you have symptoms of COVID-19, or have been in close contact with someone with COVID-

19, do the following:

􀁸 Unless fully vaccinated, residential students should stay in their dormitory room and call the Health and Wellness Center at [insert number]. Fully residential students and have COVID-19 symptoms should stay in their dormitory room.

􀁸 Non-residential students should stay home and contact the Health and Wellness Center

at [insert number].

OMB Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room N-4456, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB Control Number 1205-0548 (Job Corps COVID-19 Symptom Tracker and Attestation). Note: Please do not return the completed Job Corps COVID-19 Symptom Tracker and Attestation application to this address.

OMB Control Number: 1205-0548

OMB Expiration date: XX/XX/XXXX

ETA Form- 9194

Attachment B: Daily Emotional Wellness Checklist

Daily Emotional Wellness Checklist

Job Corps cares. We want to make sure you are doing well on center.

Name: Today’s Date:

Student ID: Time:

Please check one box for each row. How was your:

1. Sleep last night? Great Good Fair Poor

2. Appetite during the past day? Great Good Fair Poor

3. Mood during the past day? Great Good Fair Poor

4. Sense of support during the past day?

Great/ Good/ Fair/ Poor

Overall, how are you doing? Great/ Good/ Fair/ Poor

I would like to talk to someone from the Health and Wellness Center.

I am choosing not to complete this checklist.

OMB Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average .033 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room N-4456, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB Control Number 1205-0548. Note: Please do not return the completed Job Corps COVID-19 Symptom Tracker and Attestation application to this address and reference the OMB Control Number 1205-0548. Note: Please do not return the completed Daily Emotional Wellness Checklist application to this address.

OMB Control Number: 1205-0548

OMB Expiration date: XX/XX/XXXX

ETA Form- 9196