Lockport Daily COVID Screening Questionnaire Winter

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

First Name *

Last Name *

Grade *

Sport/Team *

Have you had a temperature of 100 degrees or more? *

Yes

Are you experiencing any flu like symptoms such as respiratory distress, cough, fever or chills? *

Yes

Have you had new loss of taste or smell? *

Yes

Have you had close contact with some who was confirmed or suspected of having COVID-19? *

Yes

Have you or anyone in your household traveled outside of New York State in the last 14 days, or under active quarantine due to COVID-19 exposure? *

Yes

Have you or anyone in your household tested positive for COVID-19 or awaiting test results? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lockportschools.net. Report Abuse