Stevens Creek COVID-19 Daily Screening Form for Students

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Please complete this form to assess your child's potential exposure to or diagnosis of COVID-19 or other illnesses. If you answered "yes" to any of these questions, please do not send your child to school for in-person learning. Please call and excuse his or her absence.

Student Name: *

Best contact phone number for today: *

Do you have a family or household member diagnosed with the COVID-19 virus currently or in the past 14 days? *

Yes

Has your child had any of the following symptoms in the past 14 days that are not caused by another condition? *

Yes

Fever or chills

Cough

Shortness of breath or difficulty breathing

Headache

Congestion or runny nose

Chest pain, pressure, or tightness

Fatigue or difficulty with exercise

New loss of taste or smell

Persistent muscle aches or pains

Sore throat

Nausea or vomiting

Diarrhea

Has your child taken any medication to reduce a fever before coming to school today? *

Yes

Does your child have a temperature of 100.4 degrees or higher? *

Yes

Within the last 14 days, has your child been diagnosed or tested positive for COVID-19 infection? *

Yes

If "yes," what what the date of test?

YYYY

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