JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Weekly Check In
A weekly heath screening is required by St. Mary's Elementary School in order for students to be allowed entrance into the building each Monday. Please complete this form by Sunday evening. Please complete a separate form for each child you have in school.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Parent's Name
*
Your answer
Parent Email Address
*
Your answer
What grade is your child in?
*
Nursery
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
Other:
Does your child have a temperature greater than 100⁰F? *
*
Yes
No
Does your child feel well today?
*
Yes
No
Required
Has your child come in close, regular contact (within 6 feet) of someone who has a laboratory confirmed COVID-19 diagnosis within the past 14 days?
*
Yes
No
Does your child have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?
*
Your answer
Has your child traveled to any of the states on currently on the Advisory List in the last 14 days?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Diocese of Rockville Centre.
Report Abuse
Forms
