您的瀏覽器尚未啟用 JavaScript，因此無法開啟檔案。請於啟用後重新載入頁面。
Student Health Check Form
登入 Google
即可儲存進度。
瞭解詳情
* 表示必填問題
Name (First and Last)
*
您的回答
Which grade
*
Sunflower Kindergarten
Rainbow Kindergarten
1
2
3
4
5
6
7
8
必填
In the last 10 days, have you been in contact with anyone with a known case of COVID-19 virus?
*
No
Yes
Record your temperature
您的回答
Do you have any of these symptoms that are not caused by another condition?
*
No symptoms
Any symptoms have been cleared by a health care provider
Fever or chills
Cough
Shortness of breath or difficulty breathing
Muscle or body aches
Unusual or new headache in last 24 hrs
Recent loss of taste or smell
Sore throat
Tingling or numbness
Nausea or vomiting
Diarrhea
必填
IF YOU ANSWERED YES TO ANY OF THESE QUESTIONS, STAY HOME. The school will contact you directly.
提交
清除表單
請勿利用 Google 表單送出密碼。
這份表單是在 Sebastopol Charter 中建立。
檢舉濫用情形
表單
