JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Self Certification Form
Please submit this Self Certification/Health Screening form for your child prior to bringing them to West for IAR. The form needs to be completed the same day as the assessment. It also needs to be completed each time they come for the assessment. Thank you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date
*
MM
/
DD
/
YYYY
Child's First and Last Name
*
Your answer
Grade Level
*
Third Grade
Fourth Grade
Fifth Grade
Health Related Questions
Please answer yes/no to the following health related questions.
Does your child have a fever of 100.4 or greater (without fever-reducing medications)?
*
Yes
No
Does your child have a new onset of moderate to severe headache, muscle/body aches, fatigue and/or chills from an unknown case?
*
Yes
No
Does your child have a new cough and/or shortness of breath/trouble breathing NOT caused by allergies or a known pre-existing condition, such as asthma?
*
Yes
No
Does your child have a sore throat, and/or loss of taste or smell?
*
Yes
No
Has your child had any vomiting and/or diarrhea?
*
Yes
No
Has your child had close contact with, or are they caring for, somone who was tested positive for COVID-19 within the last 14 days? *Close contact is defined as within 6 feet of someone for at least 15 minutes.
*
Yes
No
If you answered YES to any of the above questions, please DO NOT send your child to West to take IAR. Email Mrs. Cruz (
kkcruz@d47.org
) to let her know.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Crystal Lake School District 47.
Report Abuse
Forms
