COVID Self-Screening Assessment - STUDENTS
This form MUST be completed each morning before your child(ren) comes to school. Please complete for each child if they are attending in-person instruction that day.
Email address *
Student's First Name *
Student's Last Name *
In-Person or Remote Student? *
Phone Number *
School - Select the school your child is currently attending. *
Grade *
Has your child been diagnosed with COVID-19 in the past 28 days? *
Does your child live with someone who has been diagnosed with COVID-19 or is still symptomatic in the past 14 days? *
Does your child have any of the following symptoms that are unexplained or different from your known health conditions: *
Yes
No
Fever 100 degrees or higher?
Chills or repeated shaking with chills?
Sore throat?
Difficulty breathing/shortness of breath?
Unexplained muscle aches?
New cough?
New loss of smell or taste?
New runny nose or nasal congestion (different from your normal allergies or seasonal hay fever)?
Vomiting or diarrhea in the last 24 hours?
In the past 14 days have you traveled outside the US or outside Maine, NH, VT, CT, NY, NJ or MA?
NOTE: Massachusetts is now exempt. *
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