PLSD COVID-19 Symptom Sheet- PHSN Band
Parents, please fill out and electronically sign the form below before EVERY band rehearsal. If you answer YES to any questions, DO NOT send your child to school and follow-up with a physician. If a student's temperature is above 100.0 degrees Fahrenheit, or you answer YES to any questions, the student MUST stay home.
Student Last Name *
Student First Name *
What section are you in? *
Student birthday *
MM
/
DD
/
YYYY
Grade for 2020-2021 School year *
Temperature (in degrees Farenheit) *
Do you have a fever? *
Do you have chills? *
Do you have a loss of sense of smell or taste? *
Do you have a cough? *
Do you have a sore throat? *
Do you have shortness of breath? *
Have you been in close contact or cared for someone with COVID-19? *
Have you traveled out of town since your last survey? If you answer yes, you must report to your band director or athletic trainer and give the date(s) and location of the trip. You are no longer required to self quarantine for 14 days, however, monitor your health and if you develop any symptoms you should contact your director immediately. Otherwise, return to band as normal. *
Next
Never submit passwords through Google Forms.
This form was created inside of Pickerington Local School District. Report Abuse