Health Screener - Bilbray ES
Fill out this brief health survey for each visitor attending campus
Sign in to Google to save your progress. Learn more
Email *
Parent/Guardian Name (LAST, FIRST) *
Symptoms Check
Does you have any of the following symptoms? *
Yes
No
New cough that cannot be attributed to another health condition
New shortness of breath that cannot be attributed to another health condition
Fever of 100 degrees or higher
Chills / Repeated shaking with chills
Muscle pain
Headache
Vomiting
Nausea
Diarrhea
Increasing congestion
Runny nose
New loss of smell or taste
Close contact with someone who has a laboratory-confirmed positive COVID-19 diagnosis in the past 14 days
Received a laboratory-confirmed positive COVID-19 diagnosis in the past 10 days
Name of your student (LAST, FIRST): *
You're Checked in for today, Thank You!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Clark County School District. Report Abuse
Google Forms