COVID Screening Form

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As we prepare to return to school on October 5, every student (or parent/guardian of a student) needs to fill out the following form. Please do so as soon as possible. If you experience any symptoms or test positive for COVID-19 after submitting this form, please contact your campus and let us know. Please submit a response for each child that you have in the district.

Student Name:

Campus:

To assist with planning purposes, do you plan on returning to Face-to-Face Learning on October 5th?

Yes

No, my student will stay remote.

Clear selection

Were you diagnosed with COVID-19?

Yes

Clear selection

If yes, what date were you diagnosed?

YYYY

Did you have COVID-19 Symptoms?

Yes

Clear selection

Have you had any symptoms for COVID-19 within the last 10 days?

Yes

Clear selection

Have you had close contact with anyone who has tested positive for COVID-19?

Yes

Clear selection

If yes, what day were you last in close contact with an individual who has tested positive for COVID-19?

YYYY

Submit

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