Forest Street Community School COVID Daily Pre-K Survey Form

您的浏览器中未启用 JavaScript，因此无法打开此文件。请启用 JavaScript，然后重新加载。

Please submit this form only on days your student reports for Hybrid Learning, no later than 8:00 AM. Note: The information collected from this form will be maintained as confidential and will be used to determine if the student has potentially been exposed to or infected with the COVID-19 virus.

电子邮件地址 *

Student First Name *

Student Last Name *

Symptoms

Any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child daily for these symptoms.

Section A - If TWO OR MORE of the fields in this Section are checked off, please keep your child home and notify the school for further instructions. *

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or runny nose

None at this time

必填

Section B - If AT LEAST ONE field in this Section is checked off, please keep your child home and notify the school for further instructions. *

Cough

Shortness of breath

Difficulty breathing

New loss of smell

New loss of taste

None at this time

必填

Close Contact/Potential Exposure

If ANY of the fields in the 'Close Contact/Potential Exposure' section are checked off, your child should remain home for 14 days from the last date of exposure (if child is a close contact of a confirmed COVID-19 case) or date of return to New Jersey.

Contact your child’s provider or your local health department for further guidance.

Please verify if: *

Your child has had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

Your child has traveled to an area of high community transmission.

Not applicable

必填

I hereby certify the answers above are being submitted as true and accurate to the best of my knowledge. (Please type your full name on the line below before clicking submit). *

向我发送我的回复的副本。

提交

清除表单内容

切勿通过 Google 表单提交密码。

reCAPTCHA

隐私权条款

此表单是在 Orange Public Schools 内部创建的。举报滥用行为

表单