Email Address of Person Filling Out Health Assessment *
Your answer
Who are you Filling out this Health Assessment for? (Your Child's Name) *
Your answer
Please answer "Yes" or "No" to the following questions. One "Yes" answer for the following questions means that your child needs to stay home today and then follow the return to school protocol accordingly. *
Yes
No
In the last 24 hours, has as your child been in close contact with a confirmed case of COVID-19 outside of school?
Has your child had a temperature at or above 100 degrees Fahrenheit in the last 24 hours?
Has your child experienced chills in the last 24 hours?
Is your child having shortness of breath or difficulty breathing?
Is your child experiencing any flu-like symptoms (nausea, vomiting, diarrhea)?
Is your child experiencing a cough?
Is your child experiencing muscle aches or fatigue?
Does your child have a headache?
Does your child have a new loss of taste or smell?
Does your child have a sore throat?
Is your child congested or experiencing a runny nose?
Yes
No
In the last 24 hours, has as your child been in close contact with a confirmed case of COVID-19 outside of school?
Has your child had a temperature at or above 100 degrees Fahrenheit in the last 24 hours?
Has your child experienced chills in the last 24 hours?
Is your child having shortness of breath or difficulty breathing?
Is your child experiencing any flu-like symptoms (nausea, vomiting, diarrhea)?
Is your child experiencing a cough?
Is your child experiencing muscle aches or fatigue?
Does your child have a headache?
Does your child have a new loss of taste or smell?
Does your child have a sore throat?
Is your child congested or experiencing a runny nose?
Thank you for taking the time to fill out this health assessment and blessings on your day!
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