KSED Daily Health Certification Form

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Use the following form to let us know if you are experiencing a fever or any of the listed symptoms (e.g., fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle/body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea.) Please keep in mind that you are not to be under the use of any fever-inhibiting medicine such as Tylenol and/or Advil, etc.

Name of Student or Staff Member: *

For KSED staff, choose your department and/or program. For students, please select your program (BLC, homebound, or walk-in students).

Temperature Check: Is there a fever present? *

Are you currently experiencing any of the COVID related symptoms? *

Yes

Required

Name of Individual Completing Form *

Please certify: *

I certify that the information provided within this form is accurate.

Required

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