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TP Child Care Screening Log
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Child’s name (as displayed on their ActiveNet account)
*
Your answer
Name of adult completing form on behalf of the child?
*
Your answer
Have you or your child felt any of the following symptoms in the last 14 days?
*
Cough
Shortness of breath
Difficulty breathing
New loss of taste or smell
Fever of 100.4 F or higher
Chills or shaking chills
Muscle aches
Headache
Sore throat
Nausea or vomiting
Diarrhea
Fatigue
Congestion or runny nose
None of the above
Are you, your child, or anyone in your household waiting for a COVID-19 test result, diagnosed with COVID-19, or instructed by any health care provider or the health department to isolate or quarantine?
*
Yes
No
In the last 14 days, did you or your child have close contact (within 6 feet for a total of 15 minutes or more in a 24-hour period) with anyone diagnosed with COVID-19 or suspected of having COVID-19 and you or your child have not completed the quarantine period?
*
Yes
No
Other:
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