High School COVID-19 Self-Screening Form

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This health screening questionnaire is offered for informational purposes to help you check for COVID-19 symptoms as outlined by the Centers for Disease Control. The guidance you receive depends on the accuracy of the information you provide as well as current guidelines for identifying symptoms associated with COVID-19. Please take the survey and provide the response to the school district. This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional for serious symptoms or emergencies.

Your health and well-being are of the upmost importance and we are taking measures to keep a safe environment for our students and staff as well as the individuals under our charge and the public. Therefore, anyone coming into the building will be screened and part of our screening process will include taking your temperature and asking the following questions.

Please complete this health screening form once per week before entering any school building. Please complete on the first day of school each week (please note, this may not always be on Monday). All students are required to wear face coverings in hallways, offices, restrooms and other confined spaces.

Thank you in advance for partnering with us to promote a safe environment for all members of the West Babylon School District community.

Email *

Child First Name *

Child Last Name *

Does your child attend the high school for live, in-person classes on BLUE days, GOLD days, or everyday? *

BLUE

GOLD

EVERYDAY

Required

What grade is your child?

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Temperature checks are required to be completed before entering our facilities. Do you have a temperature of 100.0 F or higher? *

YES

Have you had COVID-19 symptoms in the past 14 days? (The current CDC definition of symptoms includes: fever, cough, shortness of breath, or at least two of the following symptoms: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell)* *

YES

Have you had a positive COVID-19 test in the past 14 days? *

YES

Have you had close contact with confirmed or suspected COVID-19 cases in the past 14 days? *

YES

If you responded YES to any of the questions above, please do not send your child to school at this time. Please contact the high school and speak with an Administrator or our Health Office for further information. Thank you.

By checking this box I am confirming the above information is accurate. *

My responses are accurate

Required

Send me a copy of my responses.

Submit

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