COVID 19 Daily Student Screening Form

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Student Last Name *

Student First Name *

Student Temperature *

Do you have a temperature of 100F or greater? *

Yes

Do you have any TWO of these symptoms (not related to chronic, known conditions or seasonal allergies): chills, muscle aches, sore throat, nausea, fatigue, congestion/runny nose? *

Yes

Do you have any ONE of these symptoms (not related to chronic, known conditions, or season allergies): fever, cough, shortness of breath, difficulty breathing, new lost of taste/smell, vomiting, diarrhea? *

Yes

If you have answered yes to any of the above questions, please stay home and notify the school for further instructions.

Have you or anyone in your household tested positive for COVID 19 in the last 14 days OR have had close contact (within 6 feet for 15+minutes in 24 hours) with a confirmed or suspected COVID 19 case in the last 14 days? *

Yes

Do you or anyone in your household have a pending COVID test? *

Yes

Have you traveled to any of the states OTHER than New York, Pennsylvania, Connecticut or Delaware for 24 hours or longer during the last 14 days? *

Yes

If you have answered yes to any of the above question, you should remain home for 14 days from the last date of exposure (if you are in close contact of a confirmed COVID-19 case), date of return to New Jersey or COVID test is resulted.

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