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4-1 Weekly Health Survey
This survey is to be completed before the first day of each school week.
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* Indicates required question
Email
*
Your email
Student Last Name, Student First Name:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Does your child feel well today?
*
Yes
No
Does your child have a temperature greater than 100 degrees F?
*
Yes
No
Has your child come in close, regular contact (within 6 feet) of someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?
*
Yes
No
Does your child have any of the following? (Check all that apply.)
*
fever
chills
cough
shortness of breath or difficulty breathing
body aches
headache
new loss of taste or smell
sore throat
none of the above
Required
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