COVID-19 Screening Form
Harold Maxwell III
School you attend:
Cheshire High School
Coginchaug Regional High School
Lyman Hall High School
Sheehan High School
Newington High School
Notre Dame West Haven
Saint Paul Catholic High School
Wicox Tech H.S.
Have you experienced any of the following symptoms in the past 48 hours?
fever or chills
shortness of breath or difficulty breathing
muscle or body aches
new loss of taste or smell
congestion or runny nose
nausea or vomiting
Have you been in close physical contact in the last 14 days with:
Anyone who is known to have laboratory-confirmed COVID-19?
Anyone who has any symptoms consistent with COVID-19?
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are you worried that you may be sick with COVID-19?
Are you currently waiting on the results of a COVID-19 test?
Have you traveled in the past 10 days? Travel is defined as any trip that is overnight AND on public transportation, OR any trip that is overnight AND with people who are not in your household.
I certify that my responses are true and correct.
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