Daily Health Screening Form for Students - Foothill Track & Field 2021
Prior to coming in person to any of our school district campuses or buildings, please read and answer the questions below truthfully.
Sign in to Google to save your progress. Learn more
Student First Name *
Student Last Name *
If you answer “yes” to questions 3-16, students are not able to come to campus, enter a PUSD bus or other PUSD building. You may contact us via email or phone and we can coordinate an alternative means to connect with you and/or get materials to your child(ren).
Note to parents/guardian: School staff will perform a visual check according to the guidance set forth by the Alameda County COVID-19 Health Screening in TK-12 Schools and Extracurricular Programs Serving School-Age Children and Youth.  We are required to send a student home if they look ill when they arrive, even if you state that your child has no symptoms. We will look at the student for signs of illness like cough, fatigue, extreme fussiness or irritability, or difficulty breathing. If your child is sent home your family will receive follow up information from the school about when they can return in person.
(1) In the past 10 days, was the student sent home sick or absent due to illness? *
(2) In the past 10 days, was the student diagnosed with COVID-19 or did the student have a test confirming that they had the virus? *
BEFORE PROCEEDING TO QUESTION 3...
If the answer to Question 1 or 2 is YES, students may not return to school until cleared by their school site administrator.  Return criteria are outlined in the in the ACOE COVID-19 School Reopening Guidance Document (https://www.acoe.org/schoolguidance).
(3) Within the past 14 days, has the student had close contact with anyone in the household who was diagnosed with COVID-19 or who had a test confirming they have the virus? *
(4) Within the last 14 days, has the student had close contact with someone outside the household who was diagnosed with COVID-19 or who had a test confirming they have the virus? *
BEFORE PROCEEDING TO QUESTION 5...
IF YES to Question 3 or 4 → Student CANNOT attend the program
IF NO to Questions 3 & 4 → Proceed to Answering Below Questions
Does the Student have any of the following: *
Yes
No
(5) Fever or chills
(6) Cough
(7) Shortness of breath or difficulty breathing
(8) Fatigue
(9) Muscle or body aches
(10) Headache
(11) New loss of taste or smell
(12) Sore throat
(13) Congestion or runny nose
(14) Nausea or vomiting
(15) Diarrhea
(16) Seems sick or like they are starting to get sick?
IF YES to ANY of the above questions → Student CANNOT attend the program
Question for After Attendance is approved:
"I understand that students are required to wear face coverings at all times, while at school, unless exempted under CDPH guidelines.  If I have questions about this policy, I will contact my school site administrator.” *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pleasanton Unified School District. Report Abuse
Google Forms