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Parent's Weekly Acknowledgment of Completion of Student's Daily Home Screenings
Parents: Please complete this short questionnaire to acknowledging you have taken your child's temperature and assessed him/her for any symptoms of illness.
STUDENT'S FIRST NAME
STUDENT'S LAST NAME
My Student is :
Attending School 2 days and 3 days remote learning.
Attending School 4 days and 1 day remote learning.
I acknowledge I have screened my child on a daily basis for the following symptoms noted, that may indicate a possible illness that may decrease the student's ability to learn and also put them at risk for spreading illness to others.
Name of Parent/Guardian Completing Form
Description of Symptoms & Close Contact/Potential Exposure
• Temperature of 100 degrees Fahrenheit or higher when taken by mouth
• Sore throat
• New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline)
• Diarrhea, vomiting or abdominal pain
• New onset of severe headache, especially with a fever
• New onset of loss of taste or smell
Close Contact/Potential Exposure:
• Had close contact (within 6 feet of an infected person for at least 15 minutes ) with a person confirmed COVID-19
• Traveled to or lived in an area where local, Tribal, territorial, or state health department is reporting large numbers of COVID-19 cases as described in the Community Mitigation Framework?
• Live in areas of high community transmission (as described in the Community Mitigation Framework) while the school remains open?
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