FSMN Daily Health Screening Form
Please complete this form by 7:45 each morning for anyone (students, staff, and faculty) planning to enter the school building that day.
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First Name *
Last Name *
Teacher or Grade Level *
1. Do you live with someone who is being tested for COVID-19 BECAUSE they are showing symptoms of COVID-19? (If they are being tested due to close contact, but are displaying no symptoms, then you may select "No". *
2. Have you recently had contact with someone with COVID-19 or presumed to have COVID-19? *
3. Do you have any of the "more common" COVID-19 symptoms listed below? (NOTE: A single, "more common" symptom is grounds for staying home and any sibling or relative is also to stay home until a negative COVID Test, OR an alternative diagnosis OR, after 10 days .) *
Required
4. Do you have any of the "less common" COVID-19 symptoms listed below? (NOTE: A single, "less common" symptom is NOT necessarily grounds for staying home and if a student does stay home they may return after 24 hours symptom free. If experiencing two "less common" follow the same procedure as those with a single "more common" symptom.) *
Required
Please check the box that best explains the outcome of this health screening: *
Required
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