Henry Ford Student COVID-19 Screening Form
All parent/guardians must complete this survey for EACH DAY that their child comes to a school campus for any reason. Your child MAY NOT come to school and MUST stay home if:

- Your child has been diagnosed with COVID-19 in the last 10 days.
- Your child is experiencing any symptom(s) of COVID-19, including: fever, chills, cough, shortness of breath or difficulty breathing, fatigue, headache, sore throat, loss of taste or smell, muscle pain, congestion or runny nose, nausea or vomiting, diarrhea, rash, conjunctivitis or "pink eye."
- Someone in your household has been diagnosed with or placed in quarantine for possible exposure to COVID-19 within the last 14 days.
- Your child has been in close contact with anyone who has been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last 14 days or who is experiencing COVID-19 symptoms. Close contact is define as <6 feet for more than 15 minutes even if a face covering was worn.

You must report your absence to the school office.
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Please note: This screening form will be shared with site principals and secretaries so they can ensure everyone who comes on campus has been cleared to do so. This is for everyone's safety. The information you provide will NOT be shared with anyone other than District administrators, principals and secretaries and will otherwise be kept strictly confidential. The privacy of your health information is important - we have intentionally kept this form general. You are not asked to report specific symptoms or names of contacts on this form.
Student's Last Name *
Student's First Name *
Today's Date *
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Student's School *
Student's Grade/Program *
People have reported a wide range of COVID-19 symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. These symptoms could include fever, chills, cough, shortness of breath or difficulty breathing, fatigue, headache, sore throat, loss of taste or smell, muscle pain, congestion or runny nose, nausea or vomiting, diarrhea, rush, conjunctivitis or "pink eye".
Is your child currently experiencing any symptoms of COVID-19? *
Did you take your child's temperature today before coming on-site?
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Was your child's temperature below 100.4 degrees Fahrenheit or 38 degrees Celsius? *
Has your child knowingly been in close contact with anyone who has been diagnosed with, has had COVID-19 symptoms in the last 14 days, or has been placed in quarantine for possible exposure to COVID-19 within the last 14 days? *
Please check the box below to certify your understanding and acknowledgment that a parent, guardian, nanny or family member may not come to campus to drop off or pick up students if that individual has any symptoms of COVID-19 and/or has received a positive test for COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last two weeks. *
Required
Parent/Caregiver's Last Name *
Parent/Caregiver's First Name *
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