COVID-19 Screening Form

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We at Chloe Clark Elementary have student, staff and community safety as our primary concern. Our collective work as a community to prevent the virus from spreading will allow our district and schools to continue our operations. If we all take responsibility for following a few rules, our chances of preventing and containing the virus improve dramatically.

STAY HOME WHEN YOU ARE SICK OR IF YOU'VE HAD CLOSE CONTACT WITH SOMEONE WHO HAS COVID-19
WEAR A MASK AND MAINTAIN PHYSICAL DISTANCING OF 6 FEET
WASH YOUR HANDS FREQUENTLY

On the days you will be in-person at the school site, you must complete and submit this form PRIOR to leaving your home.

Email *

Visitor's name *

Have you had any of the following symptoms in the last 72 hours that are not attributable to another condition? *

Fever of 100.4 F or higher or a sense of having a fever

Cough, shortness of breath or difficulty breathing

New loss of taste or smell

Unusual fatigue

Persistent muscle aches or pains

Sore throat

Congestion/running nose - not related to seasonal allergies

Nausea, vomiting, or diarrhea

Headache

I have not had any symptoms

Required

Does anyone in your household have any of the above symptoms that are not attributable to another condition? *

Yes

Have you or anyone in your household been in close contact with anyone with suspected or confirmed COVID-19 in the past 14 days?

Yes

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Today's Date *

YYYY

Send me a copy of my responses.

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