HTCS COVID-19 Screening Form for HTCS Families. November 23, 2020
PARENTS/GUARDIANS:
- Please complete submit one form for before you come to school
- "YOU" refers to your child (you are answering the questions about your child(ren)

HTCS STAFF:
- Please submit one form for yourself before you come to school.

Symptom screening can be helpful to determine if you:
- may currently have an infectious illness that could impair your ability to work
- are at risk of transmitting an infectious illness to other individuals on the school site

Required weekly. Stay at home if you answer "yes" to any question.
Email address *
Who is completing this form? *
Parent/Guardian or Staff LAST NAME? *
Parent/Guardian or Staff FIRST NAME? *
Parent/Guardian FULL NAME? *
Student(s) Full Name *
Building Location(s) *
Required
1. Do you have any of the following symptoms: Sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, or loss of taste? *
2. Do you have a fever over 100.4 degrees? *
3. Have you or anyone in your household been in close proximity to someone who has tested positive for Covid-19 or have you tested positive within the last 14 days? *
4. Has your family traveled to a state identified by the Pennsylvania Department of Health and diocese as having high amounts of Covid-19 cases in the last 14 days? *
Required
This link will be closed by noon Monday.
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