Inspired Vision Academy Elementary/Intermediate COVID-19 Student Self-Screening Form
 The district is concerned for your safety and the safety of staff, students, and families. We are monitoring the development of Coronavirus. In the interest of ensuring a safe and healthy learning environment, we require that you monitor your health status by carefully completing this self-assessment each day before coming to campus.
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Understanding COVID-19, and How to Stay Safe
Name *
Date *
MM
/
DD
/
YYYY
Campus *
Grade Level *
Are you showing any signs of the following symptoms? *
Yes
No
Temperature 100.0° or higher
Chills, Shaking or Exaggerated Shivering
Shortness of breath, difficulty breathing
New or unexplained Cough
Congestion or runny nose
Muscle or body aches
Tiredness/Fatigue
Sore Throat
Diarrhea
Headache
Nausea or Vomiting
Loss of smell, taste, or change in taste
In the past 14 days, have you been exposed to someone with COVID-19 positive test results? *
I certify that the information provided on this form is true and correct to the best of my knowledge. *
Notes
Entering the campus premises is forbidden if there has been any YES responses to the screening checklist. If “yes” is checked, student will be directed to leave the premises. Disinfecting the affected areas will need to take place immediately.
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