MHS COVID-19 Daily Student Self-Certification

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the following daily before sending your student to school. If an answer is yes to any of the symptom questions below or your temperature is 100.4 or higher, please contact the office. Please err on the side of caution with regards to sending students to school with even mild symptoms.

If symptoms are persistent, please contact your medical professional.

If a Co-Vid 19 test is required, keep the student home until you are provided a result. Contact the building principal or school nurse upon receiving a result to determine the next course of action. If there are siblings in the home and a Co-Vid 19 test is required, the siblings should stay home as well until a result is determined. In case of a positive test, Marshall Schools will work in cooperation with Clark County Health with regards to quarantine determination for your student and any siblings.

If the symptoms the student is experiencing are due to something other than Co-Vid that is a normal condition for your student such as allergies or migraine headaches, please discuss with the building principal or school nurse (a medical release documenting the alternate diagnosis may be required). If your student has symptoms that prove to be something other than Co-Vid such as a common cold or flu, please consult with your medical professional about a return to school medical release according to what the normal criteria is for that condition.

If your answer is yes to your student having or being in contact with someone with CoVid, you will be asked if this has been in the last 14 days. If in the last 14 days, or if you have not been cleared by County Health or your Medical Professional, contact the building principal or school nurse.

If as student has a temperature that is 100.4 or higher, wait up to 1 minute and retake. If the temperature is still 100.4 or higher, please contact your building principal or school nurse.

If a student becomes ill or symptomatic at school, we will utilize the same screening criteria. If a student becomes symptomatic at school needs to be sent home, we will check-in and screen each of their siblings as well.

Thank you for your cooperation!

Student Last Name *

Student First Name *

Student Birthday *

YYYY

Grade *

Please check for the following daily with your student.

Do you have a fever, cough, chills and/or muscle aches? *

Yes

Do you have a sore throat, runny nose,and/or loss of taste or smell? *

Yes

Are you experiencing nausea, vomiting, and/or diarrhea? *

Yes

Are you experiencing shortness of breath and/or headache? *

Yes

Have you had, had close contact with, lived with, or cared for someone with COVID-19? *

Yes

If you have had, had close contact with, lived with, or cared for someone with CoVid-19, has that been in the last 14 days (If yes, contact your administrator or supervisor.) *

Yes

I have not had, had close contact with, lived with, or cared for someone with CoVid-19.

Temperature Check (if 100.4 or higher contact building principal or school nurse) *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Marshall CUSD C2. Report Abuse

Forms