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COVID-19 SCREENING
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Has your child had close contact (within 6 feet of an infected person for at least 10 minutes) with a person who tested positive for COVID-19?
*
Yes
No
Has your child or anyone in your household traveled to or lived in an area identified on state health department COVID-19 quarantine list?
*
Yes
No
Is your child experiencing one or more of the following symptoms?
*
cough
shortness of breath
difficulty breathing
new olfactory disorder
new taste disorder
none of the above
Required
Is your child experiencing two or more of the following symptoms?
*
fever (100.4 degrees or higher)
chills
shivers
muscle aches
headache
sore throat
nausea or vomiting
diarrhea
fatigues
congestion or runny none
none of the above
Required
Child's temperature
*
Your answer
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