Request edit access
Proctor/ CVUSD COVID-19 Student/Parent Screener
Daily Health Screening Questionnaire for Students and Families


Prior to coming in person to any of our school district campuses or buildings, please read and answer the questions below truthfully.
 If you answer yes to any question, please  DO NOT come onto the district or school site campus or 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).
Sign in to Google to save your progress. Learn more
Parent and or Student Name (person coming onto the school campus) *
In the past 10 days, was the student/Parent sick and instructed to isolate? *
In the past 10 days, was the student/parent diagnosed with COVID-19 or did the student/parent have a test confirming that they had the virus?   *
Within the past 14 days, has the student/parent had close contact with anyone who was diagnosed with COVID-19 or who had a test confirming they have the virus? In the past 10 days, was the student/parent diagnosed with COVID-19 or did the student/parent have a test confirming that they had the virus? *
Since the student was last at school, has the student had any of these symptoms, new or different from what they usually have or not explained by another reason (such as a pre-existing diagnosis)? Symptoms: Fever (greater than 100°F), chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, seems sick or like they are starting to get sick . *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Castro Valley USD.

Does this form look suspicious? Report

Google Forms