The Preschool at DUMC COVID Screening Form
Please fill out the information below before your child leaves for school each day.
* Required
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Child's name
*
Your answer
Child's teacher
*
Your answer
Has your child had close contact with anyone with a confirmed case of COVID-19?
*
Yes
No
Has your child or anyone in your immediate family traveled out of state within the last 14 days?
*
Yes
No
If you answered yes to the question above, to which state did your child or immediate family travel? (type N/A if answer above was no)
*
Your answer
Check any symptoms that your child has displayed that cannot be attributed to another health condition in the last 24 hours:
*
Fever
Persistent pain or pressure in chest
Difficulty breathing/shortness of breath
Cough
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea
None of the above
Required
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