Hillcrest COVID-19 Daily Screening Form for Students
Please complete this form to assess your child's potential exposure to or diagnosis of COVID-19 or other illnesses. If you answered "yes" to any of these questions, please do not send your child to school for in-person learning. Please call and excuse his or her absence.
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Student Name: *
Best contact phone number for today: *
Do you have a family or household member diagnosed with the COVID-19 virus currently or in the past 14 days? *
Has your child had any of the following symptoms in the past 14 days that are not caused by another condition? *
Yes
No
Fever or chills
Cough
Shortness of breath or difficulty breathing
Headache
Congestion or runny nose
Chest pain, pressure, or tightness
Fatigue or difficulty with exercise
New loss of taste or smell
Persistent muscle aches or pains
Sore throat
Nausea or vomiting
Diarrhea
Has your child taken any medication to reduce a fever before coming to school today? *
Does your child have a temperature of 100.4 degrees or higher? *
Within the last 14 days, has your child been diagnosed or tested positive for COVID-19 infection? *
If "yes," what what the date of test?
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