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4th Grade Program Daily Health Screening Form
Please answer our daily screening questions so we can ensure the health and safety of our participants and staff. Thank you!
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Email
*
Your email
Participant's Name
*
Your answer
Today or in the last 24 hours, has the participant or any household members had any of the following symptoms?
*
Fever (100.0º or above), felt feverish, or had chills
Cough
Sore throat
Difficulty breathing
Gastrointestinal problems (diarrhea, nausea, vomiting)?
Fatigue
Headache
New muscle aches
Any other signs of illness
None of the Above
Required
In the past 14 days, has the participant had close contact with a person known to be infected with COVID-19? *
*
Yes
No
COVID-19 Travel Order - Has the participant traveled outside of Massachusetts to any high-risk areas? (Does not include New York, New Jersey, Connecticut, Maine, Rhode Island, Vermont, New Hampshire and Hawaii)
*
Yes
No
The information provided above is fully accurate
*
Accept
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