Jefferson-Huston Citywide Program: Daily Student Health Screening Form
Daily health screens of students for COVID-19 symptoms are a recommendation of the Centers for Disease Control (CDC). ACPS, in partnership with the Alexandria Health Department (AHD), will require students to complete an online symptom checklist each day before reporting to work. This form will be submitted electronically to school nurses and administrators within each school for review each day.  If the student's temperature is 100 degrees or above OR any answers are “YES”, the student should not report to school and should contact the school and their healthcare provider if appropriate.

Families will need to complete one form per child if they have more than one child attending in-person instruction through this program.

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Email address or cell phone number (texts) *
First Name of Student *
Last Name of Student *
Student ID #
Date *
MM
/
DD
/
YYYY
Name of Parent or Guardian *
Please record your student's temperature here _______________.  If their temperature is more than 100.0 F, they may not go into in-person school. *
Please indicate "yes" or "no" to the questions below. *
YES
NO
Have they experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
Within the past 14 days, have they been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
Are they isolating or quarantining because they may have been exposed to a person with COVID-19 or are worried that they may be sick with COVID-19?
Are they currently waiting on the results of a COVID-19 test?
If an individual has a temperature above 100 degrees and/or answers YES to any of the screening questions before arriving, they should stay home and not enter the building.   Please contact your school and health care provider if appropriate.
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