PJC Health Screening Form
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Email *
What is the student's first name? *
What is the student's last name? *
What is the student's grade? *
Has the student knowingly been in close or proximate contact in the past 10 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19? *
Has the student experienced any symptoms of COVID-19 in the past 14 days? Symptoms may include but are not limited to: cough, fever, chills, sore throat, headache, loss of taste and/or smell. *
Has the student tested positive for COVID-19 in the past 14 days? *
Has the student traveled internationally or from a state with a widespread community transmission of COVID-19 per the NYS travel advisory (https://coronavirus.health.ny.gov/covid-19-travel-advisory) in the past 14 days? *
Enter your initials to sign and acknowledge that the questions have been answered honestly and accurately represent your current knowlede of the situation. *
We appreciate your cooperation in helping to keep our students, families and staff healthy. Thank you!                                        
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