Student Health Self-Assessment Form

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Student Name *

Does your child have any new and unexplained symptoms of COVID-19 or fever of 100.0 degrees Fahrenheit or higher? Symptoms of COVID-19 can include: Fever, or feeling feverish; respiratory symptoms such as runny nose, nasal congestion, sore throat, cough, or shortness of breath; general body symptoms such as muscle aches, chills, and severe fatigue; gastrointestinal symptoms such as nausea, vomiting, or diarrhea; changes in a person’s sense of taste or smell. *

Yes

Has your child had close contact with someone who is confirmed to have COVID-19 in the prior 10 days? (A person is considered a “close contact” to a person with COVID-19 if they were within 6 feet of the infected person for at least 10 minutes or longer. The 10 minutes of contact can be at one time, or cumulative over the course of the day.) *

Yes

Has your child traveled in the prior 10 days outside of New Hampshire, Vermont, Maine, Massachusetts, Connecticut, or Rhode Island? *

Yes

I attest that the answers to the above statements regarding my child's health are true to the best of my knowledge. *

Yes

Parent/guardian name *

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