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Covid Form
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* Indicates required question
Email
*
Your email
Last name
*
Your answer
First name
*
Your answer
In the past 24 hours have you experienced any of the following symptoms? Check all that apply:
*
No symptoms
Yes
cough
fever of 100 degrees or higher one prior to school
shortness of breath or difficulty breathing
sore throat
chills
muscle aches or pains (new or unexplained)
Headache not related to anything else such as allergies
new loss of taste or smell
nausea or vomiting
Diarrhea
Excessive Fatigue
Congestion or runny nose no related to allergies
Option 15
Option 16
Required
Have you or anyone in your household had close contact with someone who is sick?
*
Yes
No
In the past two weeks have you traveled to a state or region that is on the NJ advisory list?
Yes
No
Clear selection
Have you had close contact with anyone who has tested postive for COVID 19 during the past 14 days? Close contact is defined as less than 6 feet for more than 10 minutes.
*
Yes
No
Are you currently under quarantine orders?
No
Yes
Clear selection
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