CHS Student COVID-19 Daily Screening Form

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This form must be completed each day by the student's parent prior to arriving to Clifton High School.

Student Email Address (ID number@cliftonschools.net) - Email address must be typed in correctly - 6 digits for the ID followed by @cliftonschools.net - example 999999@cliftonschools.net *

Student ID Number *

Student First Name *

Student Last Name *

Do you have a temperature over 100? *

Yes

Are you experiencing TWO OR MORE of the following symptoms? Fever (measured or subjective), Chills, Rigors (shivers), Mylagia (muscle aches), Headache, Sore Throat, Nausea or Vomiting, Diarrhea, Fatigue, Congestion or Runny Nose *

Yes

Are you experiencing ANY of the following symptoms: new cough, shortness of breath, difficulty breathing, new loss of smell, new loss of taste *

Yes

In the past 14 days, have you had close contact (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with a person with confirmed COVID-19? *

Yes

Unvaccinated traveler to any U.S. state or territory outside of New York, Connecticut, Pennsylvania, and Delaware in the past 14 days? *

Yes

Is someone in your household diagnosed with COVID-19 or being tested for COVID-19 due to illness? *

Yes

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