MHS Student Daily COVID-19 Symptom Tracker

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All Mercy students must complete this health tracker form BEFORE daily entry to the school building. PLEASE USE YOUR MERCY EMAIL ADDRESS.

If you have any of the following symptoms, this indicates a possible illness and puts you at risk for spreading illness to others.

The information collected on this form will be maintained as confidential.

Email *

First Name *

Last Name *

Grade *

Have you tested positive for COVID-19, or are you awaiting COVID-19 test results? *

Yes

Are you are currently experiencing ONE or more of the following symptoms unrelated to a known pre-existing condition (e.g. asthma, allergies)? *

New cough

Shortness of breath

Difficulty breathing

New loss of taste or smell

No, I am NOT experiencing ONE or more of the above symptoms

Required

Are you currently experiencing any TWO of the following symptoms unrelated to a known pre-existing condition (e.g. asthma, allergies)? *

Fever (100.4 degrees F or greater)

Chills (rigors)

Diarrhea (2x in 24 hours)

Congestion or runny nose

Nausea or vomiting (2x in 24 hours)

Headache

Muscle aches (myalgias)

Sore throat

Fatigue

I'm only experiencing ONE of the above symptoms

No, I am NOT experiencing TWO or more of the above symptoms

Required

Have you had close contact (within 6ft for 15 minutes or greater) with anyone, including household members, who had a positive COVID-19 diagnostic (PCR) test result in the past 14 days or is awaiting COVID-19 test results? *

Yes

Have you traveled internationally within the last 14 days? *

Yes

Emergency Contact (Name)

Emergency Contact (Phone)

A copy of your responses will be emailed to the address you provided.

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