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Daily Morning Health Self-Assessment
Bristol/Burlington Health District
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Student First Name
Your answer
Student Last Name
Your answer
Grade Level
Grade 9
Grade 10
Grade 11
Grade 12
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Date
MM
/
DD
/
YYYY
My child has a fever (an elevated body temperature) of 100 degrees F. or above.
Yes
No
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My child is experiencing difficulty breathing and/or shortness of breath.
Yes
No
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My child has a persistent cough (is constantly coughing).
Yes
No
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My child has a loss of taste and/or smell.
Yes
No
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My child was diagnosed with (or tested positive for) COVID-19 within the last 14 days.
Yes
No
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My child is/was a close contact of a COVID-19 positive individual within the last 14 days.
Yes
No
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My child spent at least 24 hours in a state listed on CT’s COVID-19 Travel Advisory within the last 14 days.
Yes
No
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