K-4 SCHOOL SYMPTOM SCREENING: PARENT/GUARDIAN ATTESTATION                              For any individual who cannot accurately respond for themselves
Upon entry to school, the screener must direct the questions below to the accompanying
individual who can respond accurately on behalf of the person . If the answer is “yes”
to any of the questions below, that individual must be excluded from school .

For more detailed steps on how to respond to a “yes” on any of the questions below, screeners and school leaders
should refer to the Reference Guide for Suspected, Presumptive, or Confirmed Cases of COVID-19 .
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Grade Level *
Teacher's Last Name *
Child's First Name: *
Child's Last Name: *
Parent/Guardian First Name: *
Parent/Guardian Last Name: *
Parent/Guardian Phone Number: *
Has the individual you are dropping off been diagnosed with Covid-19 since they were last at school? *
• If No, move on to Question 3.
• If Yes, say and ask: They cannot go to school .
(ONLY ANSWER THIS QUESTION IF YOU ANSWERED 'YES' TO THE PREVIOUS QUESTION) Does anyone else who lives with them also go to or work at this school?
Clear selection
Has the individual you are dropping of had any of the following symptoms since they were last at school?
• If No, move on to Question 5.
• If Yes, say and ask: They cannot go to school .
(ONLY ANSWER THIS QUESTION IF YOU ANSWERED 'YES' TO THE PREVIOUS QUESTION) Does anyone else who lives with them also go to or work at this school?
Clear selection
Has the individual you're dropping off had close contact (between within 6 feet of someone diagnosed with COVID-19 for a commutative total of 15 minutes over a 24 hour time period) in the last 14 days? *
• If No, move on to next.
• If Yes,say: They cannot go to school .
Has any health department staff or a health care provider been in contact with the person you are dropping off and advised them to quarantine? *
• If No, The person may go to school
• If Yes,say: They cannot go to school .
I attest that all of the information is true to the best of my knowledge as of : *
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First Name *
Last Name *
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