COVID-19 Daily Pre-Screen

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This form must be completed daily prior to access to Fiddlehead School by any staff member, student, or visitor. In addition to completing this form, those in attendance will have their temperature taken and will be required to wear a mask in order to enter. Properly fitting face coverings are required by all visitors to the building and will be provided to those who do not have one. Anyone who fails to pass this screening or wear a face covering will be denied entry to the school grounds. Anyone with a change to their health status during the day will be asked to leave. Students who become symptomatic during the day will be isolated pending pick up by a parent or guardian.

Last Name *

First Name *

Role of person entering the building *

Staff

Student

Visitor

Have you been in close contact with a person with COVID-19? (Close contact includes 15 or more minutes spent within six feet of a person with the virus.) *

Yes (if Yes, please complete this entire form but do NOT enter the building)

Maybe (if Maybe, please contact a member of the administration before entering the building)

Have you had a fever of 100.4 or greater or used any fever reducing medications for the purpose of fever in the last 24 hours? *

Yes (if Yes, please complete this entire form but do not enter the building)

Do you have any of the following symptoms? (If the answer is Yes to ANY of the following, complete this entire form and do not enter the building.) *

Cough

Shortness of breath or difficulty breathing

New loss of taste or smell

Sore throat

Chills

None of the above

Required

Do you have any of the following symptoms as new or unexplained illnesses? (If you have TWO OR MORE of the following, please complete this form but do not enter the building.) *

Muscle aches

Nausea, vomiting, diarrhea

Fatigue

Headache

Congestion/stuffy nose

None of the above

Required

Is anyone in your immediate household ill with suspected COVID-19, a fever of 100.4, a new cough, or shortness of breath? *

Yes (If Yes, please do not enter the building and contact a school administrator)

Have you traveled outside of New England in the last 14 days? *

Yes (Please contact school nurse to discuss)

Do you affirm your answers to the above reflect a period of time no greater than 24 hours and are an honest assessment of the risk you or your child will introduce to the school community? *

Yes

Not sure (If you are not sure, please contact a school administrator before returning to school)

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