COVID-19 Weekly Mandatory Health Screening Questionnaire (Elementary)
This Questionnaire is ONLY for elementary Nursery-5th grade students.
This is a mandatory health questionnaire per child at Al-Madinah School. The health and safety of our employees, students, and visitors is always of paramount importance and is especially highlighted during the current time of the COVID-19 pandemic. The following questionnaire will be used to track the contact details and symptoms of everyone entering the building. By keeping track of the symptoms of everyone entering the building, we can take steps to prevent the spread of COVID-19. In an effort to reduce the risk of COVID-19 exposure, all students/parents for younger students must answer the following questions. If you have more than one child in school, please make sure you fill in one for each.Thank you.
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Student First Name *
Student Last Name *
Parent/Guardian   Name *
Grade *
Phone Number: (preferred Cell for texting): *
In the past 14 days, have you or someone in your household, had close, unprotected contact with a suspected or known COVID-19 patient ? *
In the past 14 days, have you or anyone in your household traveled domestically or internationally? *
Within the past 10 days, have you or anyone in your household experienced a fever of 100.4 F , a new cough, new loss of taste or smell, or shortness of breath ? *
In the past 10 days, have you or anyone in your household tested positive for COVID-19? *
I hereby confirm that the information provided above is accurate, correct and complete. *
Required
*** If you have one than one child in elementary school, please make sure you fill in one for each.Thank you. Middle School and High School will be done separately by students.
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