RBCS Health Screening Form/Formulario de Chequeo de Salud RBCS

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Please complete the following health screening form if your child is sick or absent. Please complete a separate form for each student./Por favor complete el siguiente formulario de chequeo de salud si su hijo/a esta enfermo/a o ausente.

Email *

Full Name of Student/Nombre Completo del Estudiante *

Grade/Grado *

Pre K

Kindergarten

Required

Temperature of Student before school/Temperatura del Estudiante antes de escuela *

Has the Student taken any medicine today? Please list type and dosage./¿Ha tomado algún medicamento el estudiante hoy? Por favor apunte el tipo y la dosis. *

Does the student have any of the following symptoms in the last 24 hours?/¿Ha tenido el estudiante los siguientes síntomas en las ultimas 24 horas? *

Fever/Fiebre

Chills/Escalofríos

Rigors (shivers)/Temblores

Myalgia (muscle aches)/Mialgia (dolores muscular)

Headache/Dolor de Cabeza

Sore Throat/Dolor de Garganta

Nausea/Nausea

Vomiting/Vomitando

Diarrhea/Diarrea

Fatigue/Fatiga

Congestion or Runny Nose/Congestion o Agua por la Nariz

NONE of the above/NADA de la lista

Required

Does the student have any of the following symptoms in the last 24 hours?/¿Ha tenido el estudiante cualquiera de los siguiente síntomas en las ultimas 24 horas?

Cough/Tos

Shortness of Breath/Falta de Respiración

Difficulty Breathing/Dificultad al Respirar

New loss of smell/Perdida de olfato recien

New loss of taste/Perdida de sabor recien

NONE of the above/NADA de la lista

Has the student had any of the following?/¿Ha tenido el estudiante cualquiera de lo siguiente? *

Tested Positive on a Rapid or PCR Covid-19 test / Dio positivo en una prueba rápida o PCR Covid-19

Close contact (within 6 feet of an infected person for at least 15 minutes) with a person with confirmed Covid-19 within the last 14 days/Contacto de cerca (entre 6 pies con una person infectada por lo menos por 15 minutos) con alguien confirmado con Covid-19 en los ultimo 14 días

Someone in the household is diagnosed with Covid-19 within the last 14 days/Alguien en el hogar esta diagnosticado con Covid-19 entre los ultimo 14 días

International travel within the last 10 days/A viajado a nivel internacional entre los ultimo 10 días

Waiting for Covid-19 test results/Esperando los resultados de un examen de Covid-19

NONE of the above/NADA de la lista

Required

Does the student have a Doctor appointment scheduled?/¿Tiene el estudiante una cita programada con el doctor?

Yes/Si

No/No

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A copy of your responses will be emailed to the address you provided.

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