Daily COVID-19 Certification Form

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Daily COVID-19 Certification Form - Student

Email *

Parent Name/Nombre de padre *

Child's Name/Nombre de estudiante *

Select your child's classroom/Seleccione el salon de su estudiante *

Have you or anyone in your household received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a healthcare professional in the past 14 days? / ¿Usted o alguien en su hogar ha recibido un diagnóstico confirmado de coronavirus (COVID-19) mediante una prueba de coronavirus (COVID-19) o de un diagnóstico de un profesional de la salud en los últimos 14 días? *

Yes/Si

Are you or anyone in your household attempting to find a location for COVID-19 testing? / ¿Está usted o alguien en su hogar tratando de encontrar un lugar para la prueba de COVID-19? *

Yes/Si

Have you or anyone in your household had close contact with someone diagnosed with COVID-19 within the last 14 days? /¿Ha tenido usted o alguien en su hogar contacto cercano con alguien diagnosticado con COVID-19 en los últimos 14 días? *

Yes/Si

Please take your child's temperature before they get on transportation to school. Please enter the temperature here./Tome la temperatura de su estudiante antes de que se suba al transporte a la escuela. Ingrese la temperatura aquí. *

Have you or anyone in your household experienced any cold or flu-like symptoms in the last 14 days (to include: fever or temperature of greater than 100.0 degrees Fahrenheit/38 degrees Celsius, cough, difficulty breathing, sore throat, pressure in the chest, extreme fatigue, persistent headache, diarrhea, and persistent loss of smell or taste)?/¿Usted o alguien en su hogar ha tenido algún síntoma de resfriado o gripe en los últimos 14 días (que incluyen: fiebre o temperatura superior a 100.0 grados Fahrenheit / 38 grados Celsius, tos, dificultad para respirar, dolor de garganta, presión en el pecho, fatiga extrema, dolor de cabeza persistente, diarrea y pérdida persistente del olfato o del gusto)? *

Yes/Si

Has your student traveled OUTSIDE OF ILLINOIS in the past 14 days? / ¿Ha viajado su estudiante afuera de Illinois en los últimos 14 días? *

Yes/Si

If yes, please write the travel destination that was stayed in for longer than 24 hours: /En caso afirmativo, escriba el destino de viaje en el que permaneció más de 24 horas:

A copy of your responses will be emailed to the address you provided.

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