January Student Daily Health Screening
Parent: please complete this form daily before 8:00 AM.
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Email *
Student Name: *
1.  Does your child have any of the following symptoms, that indicates a possible illness that may decrease the student’s ability to learn and also put them at risk for spreading illness to others?                                                     · Temperature 100.4 degrees Fahrenheit                             · Sore Throat                                                                                            *New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline)                   · Diarrhea, vomiting, or abdominal pain                                   · New onset of severe headache, especially with a fever                                                                                                          · Shortness of breath                                                                    · Fatigue                                                                                            · Muscle or body aches                                                               · New loss of taste or smell                                                         · Congestion or runny nose                                                        · Nausea or vomiting                                                                                                                                   · Diarrhea                                                                                         *
2. To the best of your knowledge, in the past 14 days, has your child been in close contact (within 6 feet for at least 10 minutes) with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19? *
3. Has your child or a member of your household traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days? *
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