Franklin Elementary Temporary Student Health Screener

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Franklin Elementary Temporary Student Health Screener - Tuesday, September 15, 2020

This form will be utilized for student Pre-screening that is required by the ISBE and IDPH until the new Application is launched. Please take a moment to screen your children prior to sending them to school. If your child has a fever of 100.4 or has multiple symptoms that are not normal for your child during this time of the year, please keep your child home and notify the school of their absence. This is simply a precautionary measure due to the current health risks. Thank you for your help with this.

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What is the student's first name? *

What is the student's last name? *

What is the student's grade level? *

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

1.) Do you have a temperature of 100.4 or higher? *

Yes

2.) Please mark any/all of the following symptoms you are currently experiencing. *

Cough

Shortness of breath or difficult breathing

Chills

Fatigue

Muscle and body aches

Headache

Sore throat

Loss of taste or smell

Congestion or runny nose

Nausea

Vomiting

Diarrhea

None of the Above

必須

3.) Close Contact/Potential Exposure: Please mark all that apply *

In the past 14 days, had Close Contact (within 6 feet of an infected person for at least 15 minutes) with a person with confirmed COVID-19?

In the past 14 days, had close contact with (within 6 feet of an infected person for at least 15 minutes) with person under quarantine for possible exposure to CoVID19?

Traveled to or lived in an area where the local, Tribal, territorial, or state health department is reporting large numbers of COVID-19 cases.?

Have you traveled out of the country (internationally) in the past 14 days?

Have you traveled out of the State of Illinois in the past 14 days (not including Western Kentucky)?

Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?

None of the Above

必須

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