Covid-19 Screening - Two's Tu/Th

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Student Screening Questionaire

Parent Name *

Student Name *

Over the past 7 days has your child or anyone in your household experienced any of the following symptoms? Fever (99.6 or greater), Cough, Shortness of breath/difficulty breathing, Sore throat, Loss of smell or taste, Chills, Head or muscle aches, Nausea or vomiting, Diarrhea, Known contact with a person who is lab confirmed to have COVID-19 *

Yes

Have you or anyone in your household been tested for COVID-19 and are waiting to receive test results? *

Yes

Is there any reason why you feel you or anyone in your household are at a higher risk of contracting COVID-19 or experiencing complications from COVID-19 by leaving your child in our facility? If yes, please provide a brief explanation. *

Submit

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