Daily Student Health Form

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Every day, parents will need to fill out this form confirming that their child(ren) are symptom free of COVID - 19.
Any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child daily for these symptoms.

Student's Last Name *

Student's First Name *

School / Department *

Crescent

Traphagen

Middle School

High School

Section A - If TWO OR MORE of the fields in this Section are checked off, please keep your child home and notify the school for further instructions:

Fever >= 100

Chills

Rigors (Shakes)

Myalgia (Muscle Aches)

Headaches

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or Runny Nose

Section B - If AT LEAST ONE field in this Section is check off, please keep your child home and notify the school for further instructions:

Cough

Shortness of Breath

Difficulty Breathing

New loss of Smell

New loss of Taste

If ANY of the fields in the Close Contact / Potential Exposure extension are checked off, your child should remain home for 14 days from the last date of exposure. Contact your child’s school for further guidance

You have had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-10

Someone in your household is diagnosed positive of COVID-19

You have traveled to an area of high-community transmission

I confirm that my child does not have two or more of the symptoms from Section A and that they do not have one more symptoms from Section B and that they do not have any close contact / potential exposure conditions. *

OK to report to school

Not OK to report to school due to possible COVID symptoms (2 from Section A, 1 from Section B or Potential Exposure) (Call School to Report Symptons)

Not Reporting to School due to Non-Covid reason

Confirmation *

I hereby confirm that the information submitted is correct

Required

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