Health Screening Questionnaire

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Your Name (First and Last) *

How do you identify? *

Child Care Center Staff

Kean Employee (but not Child Care Center Staff)

Visitor (Not Employed by Kean)

SYMPTOMS

Section A: If Two or more of the fields in this Section are checked off, please stay home and notify the school for further instructions. *

Cough

Chills

Rigors (Shivers)

Myalgia (Muscle Aches)

Dyspepsia (Upset Stomach)

Headache

Sore Throat

Ear Ache

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or Runny Nose

None of the Above

Required

Section B – If at least one field in this section is checked off, please stay home and notify the school for further instructions. *

Fever (Measured or Subjective)

Shortness of Breath

Difficulty Breathing

New Loss of Smell

New Loss of Taste

None of the Above

Required

Verification Statement *

I verify that all information on this form is correct to the best of your knowledge

Required

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