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LMS Student Screening Tool
Please complete one form for each child. A new Screening Tool form must be completed if any of your answers change
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* Indicates required question
Parent/Guardian Phone Number
*
Your answer
Parent/Guardian Last name
*
Your answer
Parent/Guardian First Name
*
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Fever of 100.4 within the last 14 days?
*
Yes
no
Have you taken a fever reducer (Tylenol, Ibuprofen, etc.) in the last 4-8 hour?
*
Yes
No
Reason for Taking?
Your answer
Cough/Shortness of Breath?
*
Yes
No
Pneumonia/FLU - recent?
*
Yes
No
Are you having any of the following? Muscle Pain, Loss of smell or taste, diarrhea or headache
*
Yes
No
If "yes" above please explain.
Your answer
Have you had a change in taste or smell?
*
yes
No
If "yes" above please explain
Your answer
Temperature Reading?
*
Your answer
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