Daily Home Screening for Student
Please check your child for symptoms of illness and complete this checklist each morning to report your information. If any of the below items are selected, please contact the school nurse promptly. Your child will not be permitted to enter DGS, and will require clearance from the school nurse.
Sign in to Google
to save your progress.
Student first and last name:
Section 1: Symptoms
If your child has any of the Covid compatible symptoms listed below or has been in close contact with an individual diagnosed with COVID-19, this may indicate the possible presence of illness and/or risk of spreading illness to others. Please note that this chart does not include all possible symptoms and persons with COVID-19 may experience any, all, or none of these symptoms. Please check your child for these symptoms every morning and report the following concerns regarding potential exposure:
Temperature of 100.0 F or greater
Myalgia (muscle pain)
Congestion or runny nose
New or unexplained rash
New or uncontrolled cough (for those with chronic allergic/asthmatic cough, a change in your cough from baseline)
Shortness of breath
New loss of smell
New loss of taste
My child does not have any signs or symptoms of illness
Was your child given any medication for any of the symptoms listed above?
If you answered yes to question above, please give reason for medication?
Section 2: Close Contact/Potential Exposure
Within the last 14 days:
Has your child had close contact (within 6 feet for at least 15 cumulative minutes within 24 hour period ) with a person confirmed to have COVID-19?
Has your child had close contact with household member displaying symptoms of COVID-19?
Is your child or a household member currently under investigation for COVID-19 or awaiting COVID-19 test results?
Has your child or household member traveled out of state (other than NY, CT, PA, DE) or out of the country within the past 14 days?
If you answered yes to question above, where?
Has your child or a household member been advised by a medical provider or public health official to self quarantine for any reason?
Never submit passwords through Google Forms.
This form was created inside of David Gregory School.