ELEMENTARY: Daily Attestation

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Complete this form BEFORE dropping your child off at campus. EVERY DAY.
Daily health assessments for students and staff can contribute to the overall health and well-being of our MLA community. We appreciate your help in keeping our environment safe and healthy. All questions are required even if one of your answers is "yes" please fill out the entire form.

STUDENT NAME (if staff write your name) *

TEACHER NAME *

K - Cope

K - Ruddell

1 - Bradner

1 - Vue

2 - Cossu

2 - Lee

3 - Hillstrom

3 - Tyler

4 - Milly

4 - Teixeira

5 - Ward

5 - Hartung

MLAE Staff (NOT a student choice)

Which gate are you dropping your student off at: (gate is per your youngest MLA child's grade) *

Gate A: Daycare & walking students

Gate B: Kinder and 1st Grade

Gate C: 2nd Grade & 3rd Grade

Gate D: 4th Grade & 5th Grade

Staff (NOT a student choice)

Has your student experienced any of the following symptoms in the past 24 hours? *

Fever (100 or higher) or chills

Cough (NEW or worsening)

Fatigue

Muscle or body aches

Shortness of breath/difficulty breathing (NEW or worsening)

Recent loss of taste or smell

Sore throat

Congestion

Nausea or vomitting

Diarrhea

None of the above

Required

Within the past 14 days, has your student been in close physical contact (6 feet or closer for a total of 15 minutes in a 24-hour period) with: *

Anyone who is known to have laboratory-confirmed COVID-19

Anyone who has symptoms consistent with COVID-19

None of the above

Required

Is your student or someone they live with currently waiting on the results of a COVID-19 test because of symptoms of COVID-19 or exposure to COVID-19? *

Yes

Have you traveled or been in contact in the last 14 days with anyone traveling outside of the country? If answering "yes" to this question You must do the following: Get tested with a viral test 3-5 days after travel AND stay home and self-quarantine for a full 7 days after travel. Even if you test negative, stay home and self-quarantine for the full 7 days. If your test is positive, isolate yourself to protect others from getting infected. If you don’t get tested, stay home and self-quarantine for 10 days after travel. Avoid being around people who are at increased risk for severe illness for 14 days, whether you get tested or not. (This guidance comes from the latest executive order) *

Yes

Have you had contact with or cared for someone diagnosed with COVID-19 within the last 14 days? * *

Yes

If you answered YES to any questions above or checked any symptoms, KEEP YOUR STUDENT HOME. Contact their school by 10:00 AM and consult with their physician. Student may return once cleared by their Health Care Provider.

Does your student need a school provided "Grab-N-Go" meal bag for the NEXT SCHOOL DAY? (we need to tally meal counts ahead of time) If staff choose "No". *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of MLA Public Charter School. Report Abuse

Forms