Student Covid-19 Screening Form for DCSD
Student Screening Tool
Sign in to Google to save your progress. Learn more
Name *
What school do you attend? *
Current Body Temp *
Is your temperature 100.0 or above?
Have you or anyone in your household tested positive for, or had a confirmed case of COVID-19 in the past 10 days? *
Required
*Are you experiencing any COVID-19 symptoms such as (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?) **If these symptoms can not be attributed to a pre-existing condition(s).** *
Required
Has the Health Department placed you under active quarantine due to COVID-19 exposure, within the last 10 days? *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of DunkirkCSD. Report Abuse