Daily Health Screening Verification for CUSD #3 Students

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Email *

Palestine Student's Name (First, Last) *

Today's Date: *

YYYY

Time

Has your child or anyone else in your household had a temperature of 100.4 or greater, cough, shortness of breath, difficulty breathing, chills, muscle or body aches, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or new loss of taste or smell (that cannot be attributed to another health condition) in the past 2-14 days? *

Yes

Has your child had close contact with a person known to be infected, potentially infected, or exposed to someone infected with COVID-19 within the previous 14 days? Close contact includes household contact, intimate contact, or contact within 6-ft for 15 minutes or longer unless wearing N95 mask during period of contact. *

Yes

Guardian Signature, by submitting my name, I certify that the information provided above is accurate and complete to the best of my knowledge and belief. *

If you answered YES to either of the above questions, your child should not enter the building or they should leave the building immediately.

Send me a copy of my responses.

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