JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Parent Certification of Student Health Questionnaire
Please fill out this form for each of your students on a daily basis for Student Health Certification. Your help is greatly appreciated to help keep our school safe for all students.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Have you or your child traveled outside of the United States in the last 14 days
*
Choose
Yes
No
Does your child have a Temperature of 100.4 or more?
*
Choose
Yes
No
Does your child have any of the following (Check all that apply)? If so, please stay at home.
*
No Symptoms
Fever
Shortness of Breath
Cough
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore Throat
New loss of taste or smell
Other:
Required
Are you or your child ill or caring for someone who is ill?
*
Choose
Yes
No
In the previous two weeks, have you or your child had contact with someone diagnosed with Covid-19?
*
Choose
Yes
No
Parent Signature (Please Type your Full Name)
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bloom Township School District 206.
Report Abuse
Forms
