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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms