One -Time Student COVID-19 Daily  Self Checklist Sign-Off
Instructions:
Parents and guardians of all students are required to screen their student according to this checklist each day and take the student’s temperature before sending a student to school. By sending a student to school, you certify that you and your student have honestly answered NO to all of the Questions below.

If the student answers NO to all Questions, the student may attend school that day.

If the student answers YES to any of the Questions below, the student must not be sent to school.  

After exhibiting symptoms, students are required to meet all return-to-school criteria before returning to school.

If a student starts feeling sick during school or experiences the symptoms listed below, the student will be sent home immediately.

Please complete ONCE for EACH of your students PRIOR to August 19, 2020
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Email *
SELF-CHECKLIST Questions
Does the student have a temperature of 100.0°F or greater?

Is the student taking fever-reducing medicines, such as those that contain aspirin, ibuprofen or acetaminophen, in order to reduce the student's fever?

Has the student had close contact or cared for someone with COVID-19 within the past 14 days?

Has the student returned from travel outside the United States or on cruise ship or river boat within the past 14 days?

Has the student been directed to self-quarantine by a health care provider?

Has the student been directed to self-quarantine by the County or State Department of Public Health?

Is the student experiencing any of the following symptoms?
Chills
New Cough (different from allergy or asthma baseline)
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
New onset of Headache
New loss of taste or smell
Sore Throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Link to printable form: http://www.bccu2.org/uploads/7/1/5/3/71536593/student_daily_health_checklist_covid-19_revised_july_22.2020.pdf
Student Name *
Grade Level *
Student's School *
Parent/Guardian Name *
I hereby acknowledge that I have received a copy of this COVID-19 Daily Self Checklist. I understand that I am required to honestly and accurately complete this checklist for my child each day before sending my child to school. *
A copy of your responses will be emailed to the address you provided.
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