COHS Daily COVID-19 Health Questionnaire

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Name (First, Last) *

Contact Phone Number *

Grade Level *

9th

10th

11th

12th

Faculty/Staff

Guest

Have you tested positive for COVID-19 in the past 10 days? *

Yes

Have you had contact with anyone confirmed or suspected of having COVID-19 in the past 10 days? *

Yes

For the questions below, please indicate if you are experiencing any of the following symptoms:

Fever and/or chills *

Yes

Shortness of breath or difficulty breathing *

Yes

Fatigue and/or Headache *

Yes

Cough, Sore Throat, Congestion and/or Runny Nose *

Yes

Muscle Aches *

Yes

Nausea, Vomiting, or Diarrhea *

Yes

New loss of Taste and/or Smell *

Yes

If you answered yes to any of the above question, please stay home, DO NOT ENTER THE BUILDING, You will be contacted by a staff member. Thank you for taking the Daily COVID-19 Survey

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