Keene CSD Health Screening Form
*** Households with multiple children can submit one form that includes all children if they have the same health screening result. ***
The following Health Screening is to be conducted daily before the Student gets on the bus or is dropped off at school. Staff members are to do the same screening before arriving at work. Visitors will be screened at the Main entrance.
The Keene CSD Screening Form does not make any actual determination on the status of student/staff/visitor health. The form is required in order to conduct the initial determination of whether the person should attend school on any given day.
Last Name (student(s) / staff / visitor)
First Name (student(s) / staff / visitor)
Do you have any of the following Symptoms?
1. A Temperature of 100˚ or higher.
2. Other Symptoms:
Shortness of Breath
Recent loss of taste or smell
COVID-19 specific Questions:
3. Have you had a positive COVID-19 Test within the last 14 days?
4. Have you been in close contact (within 6 feet for at least 15 minutes) with any confirmed or suspected person having COVID-19 within the last 14 days?
What were your answers to the above questions?
I answered NO to ALL of the Symptoms and Questions.
I answered YES to one or more Symptoms and Questions.
If you Checked the NO box above, the student / staff / visitor is initially cleared to attend school.
If you Checked the YES box above, the student / staff / visitor is NOT initially cleared to attend school.
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This form was created inside of Keene Central School.