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Weekly Health Screening Questionnaire
Ckids GROW
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Child Name 1
*
Your answer
Child Name 2
Your answer
Has anyone in your family been exposed to anyone suspected or confirmed to have COVID-19 in the past 14 days?
*
Yes
No
Has anyone in your home been out of state in the last 14 days?
*
Yes
No
Has your child had any medication to reduce a fever before coming to school?
*
Yes
No
Does anyone in your family/household have any of the following symptoms now or since your child’s last attendance, that you cannot connect to another health problem or reason? (Check all that apply)
Fever (100.4°F or higher)
Cough or Shortness of Breath
Headache
Sore Throat
Chills or Shaking
Muscle Aches
Diarrhea
Nausea/Vomiting
Abdominal Pain
Runny Nose
Loss of Taste or Smell (adults only)
COVID Toe (red/purple swelling)
Thank you for filling out the Health Questionnaire and ensuring the safety of everyone at Ckids Hebrew School!
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