GMA COVID-19 Screening

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Weekly Covid-19 screening agreement to be completed by 8am every Friday for the following week of school attendance. Students will not be permitted to attend school without weekly verification form completed the Friday prior to the next school week.

Email *

Student last name *

Student first name *

Teacher's name *

Please check each item to verify understanding of current GMA COVID-19 screening expectations. *

I will screen my student before school for the following and will not send him or her to school if any of these symptoms are present: fever of 100.4 or greater, nasal congestion or runny nose, cough, shortness of breath, difficulty breathing, diarrhea, nausea, vomiting, sore throat, muscle pain, fatigue, chills, and loss of taste or smell.|1

I will not send my child to school if she or he was in close contact with anyone confirmed with COVID-19. Close contact defined as per CDC and Indiana Department of Health guidelines as anyone within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24 hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection), provided care at home to someone who is sick with COVID-19, direct physical contact with the person (hugged or kissed them), shared eating utensils, or they sneezed, coughed, or somehow got respiratory droplets on you.|1

I will not send my student or other household members to school if she or he has pending COVID-19 test results or has received a positive COVID-19 test result.

I understand that my child must follow GMA's face covering policy at all times and that she or he may be sent home if she or he will not comply with the face covering protocols.

My student has not traveled outside of the United States, to an area of the United States designated as an area of particular COVID-19 infection concern by a government agency, or come into contact with anyone who has traveled to one of the foregoing areas in the most recent 14 days prior the week for this screening.

Required

Completing this form verifies that I will screen my GMA student before sending him/her to school. If, after my student's entry into GMA property, GMA learns that my student has developed one of the symptoms listed above, traveled to one of areas listed above in the most recent 14 days, or come in contact with a person in one in one of the categories listed above, GMA will promptly notify me. I agree to comply with any instructions GMA gives me as soon as possible, including, but not limited to, an instruction to immediately pick up my child from school and/or self-quarantine.

Please enter your name and week you are verifying for below for response completion.

Verification for week of: *

Respondent’s First and Last name *

Send me a copy of my responses.

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