Student Daily Health Screening Form
This form is REQUIRED to be completed if the student has any COVID type symptoms. If the answer to any of the below questions is yes, please contact Director of Alternative Learning Services at 972-923-4695 or abenskin@wisd.org  or hsocmail@wisd.org for instructions.  

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Email *
Date *
MM
/
DD
/
YYYY
Student I.D. # *
10 points
Last Name *
10 points
First Name *
10 points
Are you now, or in the past 14 days, experiencing any of the following signs/symptoms of COVID-19? Please mark any sign/symptom that you have been experiencing or mark "none of these."
20 points
Column 1
Cough
Shortness of breath/ difficulty Breathing
Repeated shaking w chills
Muscle Pain
Headache
Sore Throat
Loss of Taste or Smell
Diarrhea
Feeling feverish or a temperature greater than or equal to 100 degrees.
Known close contact with an individual with a lab-confirmed case of COVID-19
None of these
I understand  I need to email the director of Alternative Learning. Email hsocmail@wisd.org or abenskin@wisd.org *
10 points
Answering YES to ANY of the above questions means you do not report to a district facility until you've been given further instructions by the the Director of Alternative Learning. Contact via email or phone hsocmail@wisd.org or call 972-923-4695 to determine                                                                                       next steps.
10 points
Clear selection
I certify that to the best of my knowledge, my responses to the above questions are true. * *
10 points
Required
Electronic Signature *
10 points
Email & Phone Number *
10 points
Submit
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