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Health Screening Form
Please answer the following questions and follow directions as requested.
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* Indicates required question
LAST NAME of Student/Staff (1 per Household)
*
Your answer
Do you have any of the following symptoms? (Check all that apply)
*
● A fever of 100.4° F (38°C) or greater
● A Cough
● Shortness of breath/difficulty breathing
● Chills
● Sore throat
● Loss of taste or smell
● Nausea / Vomiting / Diarrhea
NO Symptoms
Required
Do you have any 2 or more of the following symptoms? (Check all that apply)
*
Muscle Pain
Stomach Pain
Fatigue
Headache
Rash
Red eyes/Eye Drainage
Congestion/Runny Nose
NO SYMPTOMS
Required
If you marked yes to the any of the of the FIRST BOX OF SYMPTOMS, or have 2 or more symptoms from the 3rd box, please do the following. * Please stay home * Contact School 734-2251 * Contact your medical caregiver *
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