Keene CSD Health Screening Form
*** Households with multiple children can submit one form that includes all children if they have the same health screening result. ***

The following Health Screening is to be conducted daily before the Student gets on the bus or is dropped off at school.  Staff members are to do the same screening before arriving at work.  Visitors will be screened at the Main entrance.

The Keene CSD Screening Form does not make any actual determination on the status of student/staff/visitor health.   The form is required in order to conduct the initial determination of whether the person should attend school on any given day.
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Email *
Last Name (student(s) / staff / visitor) *
First Name (student(s) / staff / visitor) *
Do you have any of the following Symptoms?
1.  A Temperature of 100˚ or higher.

2. Other Symptoms:

Feel feverish of have chills
Shortness of Breath
Headache
Sore Throat
Muscle Aches/Pains
Nausea, vomiting, diarrhea
Cough
The recent loss of taste or smell
Nasal Congestion/Runny Nose
Fatigue/feeling of tiredness
COVID-19 specific Questions:
3.  Have you had a positive COVID-19 Test within the last 14 days?

4.  Have you been identified as a close contact of a person who tested positive for COVID-19, by the County Health Department within the last 14 days?
What were your answers to the above questions? *
Determination
If you Checked the NO box above, the student / staff / visitor IS initially cleared to attend school.

If you Checked the YES box above, the student / staff / visitor is NOT initially cleared to attend school.
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