COVID Self-Screening Assessment - STUDENTS
This form MUST be completed Monday through Friday - for both in-person AND remote students.  Please complete daily for EACH child.
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Email *
Student's First Name *
Student's Last Name *
In-Person or Remote Student? *
Phone Number *
School - Select the school your child is currently attending. *
Grade *
Has your child tested positive for COVID-19 in the past 10 days? *
In your household OR in the community, has your child had close contact with someone who has tested positive for COVID-19 in the past 10 days? *
Does your child have any of the following symptoms that are unexplained or different from your known health conditions: *
Yes
No
Fever 100 degrees or higher?
Chills or repeated shaking with chills?
Sore throat?
Difficulty breathing/shortness of breath?
New muscle aches?
New cough?
New loss of smell or taste?
New runny nose or nasal congestion (different from your normal allergies or seasonal hay fever)?
Vomiting or diarrhea (3 or more loose stools in 24 hours)?
Fatigue?
Headache?
In the past 10 days have you traveled outside the US or outside Maine, NH, or VT?   *
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