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Covid Questionnaire
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* Indicates required question
Your name and relation to the student
*
Your answer
Student Name (first and last)
*
Your answer
Student DOB
*
MM
/
DD
/
YYYY
My child has
*
received a positive covid test result
has one of the following (loss of taste/smell, fever, consistent cough, vomiting)
has two or more of the following (headache, sore throat, fatigue, aches, chills, nausea, diarrhea, nasal congestion)
has been in close contact with someone who is covid positive
N/A
Other:
Required
If symptomatic when did symptoms begin
MM
/
DD
/
YYYY
If positive, when was the test performed
MM
/
DD
/
YYYY
If close contact, when did the contact occur
MM
/
DD
/
YYYY
Feel free to describe situation here. If close contact, please include who was the close contact and are they in the same household?
*
Your answer
If Covid exposure is from within the same house hold, is the student fully vaccinated? If so, and they have NO symptoms then they are not required to quarantine.
*
yes
no
unknown
n/a
Other:
Last day at school attended
*
MM
/
DD
/
YYYY
Do you plan on getting your child tested for covid? We recommend that they get tested 5 days after exposure and return after a negative result is received.
*
Yes
No
Maybe
n/a
Other:
Does Your Child Ride the Bus?
Yes
No
Clear selection
If your child presently participates in extracurricular activies such as sports or clubs, please list them.
Your answer
Best email to contact you
*
Your answer
Best phone number to contact you
*
Your answer
Do you have any other questions or concerns to relay to your school nurse?
*
Your answer
Would you like a nurse to contact you?
Yes - by email
No
Other:
Clear selection
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