Daily Health Screening Assessment

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Must fill out daily before entry into childcare.

Your First Name *

Your Last Name *

Is you/your child's temperature over 100 degrees F? *

YES

Is the child or any one in your household experiencing any of the following symptoms that are NOT due to an existing /ongoing medical condition: ○ cough ○ shortness of breath or trouble breathing ○ body aches ○ sore throat ○ eye discharge ○ nausea/vomiting or diarrhea ○ NEW loss of taste or smell ● Has anyone been diagnosed with, or tested positive for, COVID-19 within the past 14 days? ● Has anyone been directed to self-isolate by a public health authority or by a healthcare provider due to potential exposure to COVID-19 within the past 14 days?● Has anyone had close contact (within six feet) with anyone known to be under quarantine or diagnosed with COVID-19 or has shown symptoms of COVID-19 in the past 14 days? *

yes

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