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La Salle High School Student Screening
Student MUST fill out Checklist before coming to school.
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* Indicates required question
Fill in this form once per day. Do not combine the first name of Students in the same household with the same last names.
This form will start collecting data at 12:00 AM every day and stop at 3:00 pm.
Student's First Name
*
First name as it appears on school registration
Your answer
Student's Last Name
*
Last name as it appears on registration
Your answer
1.
Do you or any family member (in the household) CURRENTLY have ANY of the following SYMPTOMS that cannot be connected to another health issue?
*
Symptoms present within the past 24-hours
No
Yes
COUGH
SHORTNESS OF BREATH OR DIFFICULTY BREATHING
SORE THROAT
CHILLS
RECENT LOSS OF TASTE OR SMELL
HEADACHES
CONGESTION OR RUNNY NOSE
NAUSEA OR VOMITING
DIARRHEA
No
Yes
COUGH
SHORTNESS OF BREATH OR DIFFICULTY BREATHING
SORE THROAT
CHILLS
RECENT LOSS OF TASTE OR SMELL
HEADACHES
CONGESTION OR RUNNY NOSE
NAUSEA OR VOMITING
DIARRHEA
2. Have you or any family member (in the household) been in close contact in the last 14-days with an individual diagnosed with COVID-19?
*
No
Yes
3.
Have you taken Tylenol or Ibuprofen in the last six hours to treat a fever or chills?
*
(Advil, Motrin or other generic medication used or prescribed to reduce fever or chills)
No
Yes
Staying Home?
*
Answer "Yes" to Staying Home shows your intent to remain home. This will be communicated to the school's administrators and attendance office.
No
Yes
If you answer "YES" to any question, please stay home for today and let your parent(s) know. A "YES" response will send an email to the school's administrative personnel and you will be contacted later this afternoon.
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This form was created inside of Catholic Charities Serving Central Washington.
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