COVID-19 Student Bi-Weekly Screening Affidavit Updated 9.23.20
This must be done for EVERY student every 2 weeks.
Due dates are: 9/14, 9/28, 10/12, 10/26, 11/9, 11/23, 12/7, 12/21, 1/4, 1/18, 2/1, 2/15, 3/1, 3/15, 3/29, 4/12, 4/26, 5/10, 5/24, 6/7, and 6/21.
Student LAST Name *
Student FIRST Name *
School Attending *
Health Screening
Please answer to the best of your ability, if you can answer No, to the following questions, you will be prompted to submit the form via Section 2. If you can answer Yes to any of the following questions, you will be prompted to answer additional questions in Section 3. If you can answer Yes to the additional questions, you will be able to submit the form. If you answer No to any of the additional questions, please contact the school immediately and do NOT submit this form.
Screening Questions:
1. Has your child knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19?

2. Has your child tested positive through a diagnostic test for COVID-19 in the past 14 days?

3. Has your child experienced any symptoms of COVID-19, including being extremely tired, dry cough, shortness of breath, loss of sense of smell or taste, nausea, vomiting, or diarrhea?

4. Has your child experienced a temperature of greater than 100.0°F in the past 14 days?

5. Has your child traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days?
How do you respond to the above questions? *
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