JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Covid-19 Screening - Students
Answer the following questions daily for each child attending Amelia Academy. You will need to submit a separate response for each child.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Last name
*
Your answer
First Name
*
Your answer
Does your child have any of the following symptoms of COVID-19? (check all that apply)
*
None
Fever of 100.4 degrees or higher Fahrenheit when taken by mouth
Sore Throat
NEW uncontrolled cough that causes difficulty breathing
Diarrhea, vomiting, or abdominal pain
NEW onset of severe headache, especially with a fever
NEW Loss of the sense of taste or smell
Required
Has your child traveled outside the central Virginia region in the past 14 days?
*
Yes
No
Required
Has your child or anyone in your family been exposed to COVID-19 in the past 14 days?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
