JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Covid Screening
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Last Name
*
Your answer
Fever of 100.4 or greater?
*
Yes
No
Sore Throat?
*
Yes
No
New Uncontrolled Cough that causes Difficulty Breathing?
*
Yes
No
Diarrhea, vomiting or abdominal Pain?
*
Yes
No
New onset of severe headache, especially with a fever?
*
Yes
No
Identified as having COVID-19, and not cleared to return?
*
Yes
No
Close contact with a confirmed case of COVID-19 in the Past 14 Days?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of South Dakota K-12 Data Center.
Report Abuse
Forms
