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Daily Screening Form
Use one form for each day. The daily deadline to submit this form is 30 minutes before the start of the school day. If you did not submit the e-form in time please print out this form and have your child walk in to the school with the paper form.
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* Indicates required question
Email
*
Your email
Family name:
*
Your answer
This form covers the following individuals:
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Your answer
Has anyone in you household been in a hotspot in the last 7 days? (Hotspots include Crown Heights, Lakewood etc in addition to the list found here
https://www.chicago.gov/city/en/sites/covid-19/home/emergency-travel-order.html
)
*
Yes
No
Has anyone in your household had a fever of 100° F or above in the last 24 hours?
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Yes
No
Is anyone in your household experiencing any of the following symptoms: shortness of breath, having trouble breathing, have a dry cough, a sore throat, a runny nose, loss of taste or smell, chills or repeated shaking, or muscle pain?
*
Yes
No
Has anyone in your household been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Yes
No
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Name of individual filling out this form:
*
Your answer
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This form was created inside of Cheder Lubavitch Hebrew Day School.
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