Daily Student & Staff Health Screening

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Please answer the following (Please fill out the form for each child and submit it prior to entering facility):

Date: *

YYYY

Student/Employee Name: *

Guardian Name: *

Q1: Have you experienced any ONE 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 or Vomiting, or Diarrhea? *

Yes

Q2: Have you been in close physical contact in the last 14 days with: *

Yes

Anyone who is known to have laboratory-confirmed COVID-19?

Anyone who has any symptoms consistent with COVID-19?

Q3: Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *

Yes

Q4: Are you currently waiting on the results of a COVID-19 test? *

Yes

Q5: Have you traveled in the past 10 days? *

Yes

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