ACF COVID-19 Assessment (ACF新冠評估表)
The screening should be completed Friday evening or Sunday morning before coming to ACF. A new form should be filled for each child. 請於每周五晚上或主日到達會所之前完成健康篩檢。 每周需要為每個孩子填寫一份表格。
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Your First and Last Name (Parent/Legal Guardian) 您的姓名(父母/監護人) *
Your mobile number. We will text you if we need you to come to the classroom to bring your child home. 請告知您的手機號碼。 如果需要您去教室接孩子回家,我們會發簡訊給您。
Child's First and Last Name 孩子姓名 *
Does your child have any of the following symptoms? (Check all that apply) 您的孩子是否有以下癥狀(請選擇所有適用選項) *
Required
Has your child been in close contact (more than 15 minutes in 24 hours, and within 6 feet) with someone who has a confirmed COVID-19 diagnosis? 您的孩子是否與有確認新冠病毒患者有親密接觸(二十四小時內超過十五分鐘六英尺以內接觸)? *
Please select one: 以下請選一: *
I have completed this screening to the best of my ability with information I believe to be correct. I understand that if my child exhibits any of these symptoms during class, I will be notified and it is my responsibility to take my child home immediately. 我已盡力根據我認為正確的資訊填寫這份健康篩檢表。 如果我的孩子在課堂上表現出以上癥狀,我會接到通知,並有責任立即帶我的孩子回家。 *
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