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Evening School Daily Health Screening Form
Please complete this form everyday before 5 pm.
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Parent Name
*
Your answer
Student Name
*
Your answer
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
*
Yes
No
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)?
*
Yes
No
If you have answered "YES" to any of the questions listed above please inform the school and keep your child home.
By printing your name below you verify that the above information is correct.
Parents Name/Sign
*
Your answer
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