Ms. Burns Pre-k 3 January Student Health Screening Form
Please complete and submit every morning before 8:15am
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Email *
Student Name *
Email Address *
Does your child have any of the following symptoms, that indicates a possible illness that may decrease the student’s ability to learn and also put them at risk for spreading illness to others? · Temperature 100.4 degrees Fahrenheit · Sore Throat *New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline) · Diarrhea, vomiting, or abdominal pain · New onset of severe headache, especially with a fever · Shortness of breath · Fatigue · Muscle or body aches · New loss of taste or smell · Congestion or runny nose · Nausea or vomiting · Diarrhea *
To the best of your knowledge, in the past 14 days, has your child been in close contact (within 6 feet for at least 10 minutes) with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19? * *
Has your child or a member of your household traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days. *
A copy of your responses will be emailed to the address you provided.
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