COVID-19 Screening Form

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Please complete for Monday, January 4, 2021

Family Name *

Children name and grades *

Part A: In the past 24 hours, have you experienced any Flu Like symptoms? If you answered YES to any of the symptoms listed above STOP ! you will not be admitted to the facilities You MUST Self-isolate at home and contact your primary care doctor for directions. *

Sore throat

Cough

Fever

Other flu symptoms, headache, nausea or runny nose

NONE of the ABOVE

Other:

Required

Part B: In the past 14 days, have you: Had close contact, i.e., within 6 feet, of a person diagnosed with COVID-19? or Traveled internationally by plane? If you answered YES you are not permitted to enter the facilities and should self-quarantine at home for 14 days following close contact with the COVID-19 positive person or return from international travel. **Please NOTIFY the School Office if you answered YES to any of the above A or B Questions above *

YES

Other:

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