Daily Health Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The following form 𝙢𝙪𝙨𝙩 be completed by the St. Joseph's Academy student 𝗽𝗿𝗶𝗼𝗿 𝘁𝗼 𝗲𝗻𝘁𝗲𝗿𝗶𝗻𝗴 𝘁𝗵𝗲 𝗯𝘂𝗶𝗹𝗱𝗶𝗻𝗴 every morning.

Email *

First Name *

Class year: *

Have you been in direct, close contact (closer than 6 feet for 15 minutes or more) with an individual with a confirmed case of COVID-19 within the past 14 days? *

Yes

Is your temperature above 100 degrees? *

Yes

By submitting this form, you are confirming that all of the above is accurate today. *

Yes

Do you have any of the following symptoms? Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting or diarrhea *

Yes

Last Name *

Did you take your temperature today? (an oral thermometer is strongly recommended) *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of St. Joseph's Academy. Report Abuse

Forms