HS/MS Student Health Questionnaire

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Since your child's last day of school have they experienced a fever or two or more of these new or worsening symptoms?
Symptoms include cough, shortness of breath, chills, muscle pain, headache, sore throat, diarrhea, vomiting, nausea, nasal congestion/runny nose, fatigue, abdominal pain, loss of appetite, loss of taste or smell.

In the past 10 days, has your child been tested for COVID--19 with a positive result OR been tested and still waiting the test results?

In the last 10 days, has your child been in close contact (within 6 feet for at least 10 minutes) with an individual with a confirmed case of COVID-19 and waiting for release from the Department of Health?

*If your child tested positive for Covid or has been fully vaccinated within the last 90 days and is ASYMPOMATIC please select CLEARED.

Student Last Name *

Student First Name *

Grade *

Please check if your child is "Cleared" (answered NO to ALL questions) or "Not Cleared" (answered YES to ANY question) *

Cleared (your child is cleared to go to school today)

Not Cleared (please keep your child home and contact the school attendance office)

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