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CAPCS Student Daily Symptom Survey Grs. 3-9
In an effort to reduce the risk of COVID-19 exposure to College Achieve students and employees all persons entering the building must complete the following screening questions.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Student First and Last Name
*
Your answer
Grade
*
Your answer
Parent First and Last Name
*
Your answer
Phone Number
*
Your answer
Has the student traveled out of the country or has the student been in contact with anyone who has traveled to high-risk areas within the last 14 days?
*
Choose
Yes
No
Has the student had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
*
Choose
Yes
No
Has the student experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problems)?
*
Choose
Yes
No
Type your full name below as your signature and attestation that all provided responses are truthful.
*
Your answer
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