Islands HS COVID Notification and Screening Form (2022-2023)

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Student Last Name, First Name *

Parent/Guardian Name
*

Parent/Guardian Contact Information
*

In the last 10 days, has your child tested positive for COVID-19?
*

Yes

In the last 7 days, do you know or believe that you had a School based Close Contact or a Community Based Contact (household, carpool, social gathering, travel, event, etc) with anyone confirmed to have COVID-19? The CDC defines Close Contact as “any individual who was within 6 feet of an infected person for at least 15 minutes over a 24-hour period, starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection) until the time the patient is isolated.”
*

School-based

Community-based

Not sure

In the last 7 days, have you experienced, or are you currently experiencing, any new or unusual symptoms not experienced before as follows:
*

Fever of 100.4° or greater orally, or 99.4° with SCCPSS adopted kiosk thermal and non-touch handheld thermometers

Shortness of breath or difficulty breathing

Sore Throat

Congestion or runny nose

New cough

Headaches

Vomiting, diarrhea, or nausea

Muscle aches or body aches,

Fatigue

None of the above

Required

When did you have your COVID test completed?
*

Where did you get tested?
*

When did you begin having symptoms?
*

When was the last day you attended school?
*

If you ride the bus, what is the route number?
*

If you play sports or participate in school-based clubs (band, FFA, FBLA, etc.), what are they? When did you last attend?
*

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