The Preschool at DUMC COVID Screening Form
Please fill out the information below before your child leaves for school each day.
Date *
MM
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DD
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YYYY
Time *
Time
:
Child's name *
Child's teacher *
Has your child had close contact with anyone with a confirmed case of COVID-19? *
Has your child or anyone in your immediate family traveled out of state within the last 14 days? *
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) *
Check any symptoms that your child has displayed that cannot be attributed to another health condition in the last 24 hours: *
Required
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