GISSV - Self Health Screening - Daily Requirement for Essential Worker Child Care

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Parents are required to complete this form each morning shortly for each child attending Essential Worker Child Care at GISSV. If

Email *

Name of student (one form per student) *

1. Within the last 14 days have you or your child been diagnosed with COVID-19 or had a test confirming you have the virus? *

Yes

If you answered above question 1 with yes: STAY HOME and seek medical care.

2. Do you live in the same household with, or have you had close contact with,someone who in the past 14 days has been in isolation for COVID-19 or had a test confirming they have the virus? Close contact is less than 6 feet for 15 minutes or more. *

Yes

If you answered above question 2 with yes: STAY HOME and seek medical care and testing.

3a. Have you or your child had any one or more of these symptoms today or within the past 3 days?

• Fever of 100.4 degrees F or more • Repeated shaking with chills • Cough • Loss of taste or smell •Shortness of breath or difficulty breathing *

Yes

If you answered above question 3a with yes: STAY HOME and seek medical care and testing.

3b. Have you or your child had any one or more of these symptoms today or within the past 3 days and that are new or not explained by another reason?

• Congestion or runny nose • Fatigue • Muscle or body aches • Headache • Sore throat • Nausea, vomiting, or diarrhea *

Yes

If you answered above question 3b with yes: STAY HOME and seek medical care and testing.

If you have answered NO to all of the above questions, your child is cleared for Essential Worker Child care for today.

Send me a copy of my responses.

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