Marquette Catholic Health Screening Form
Alton, IL - This form should be completed by a parent/guardian with their student present to help provide the most detailed information possible
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Email *
Is the student fully vaccinated? *
In what State does the student live? *
Student Name (First and Last) *
Student Cell Phone *
Student Grade *
Parent or Guardian Name (First and Last) *
Parent Phone Number *
What is the last day the student was physically present at Marquette? *
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Is the student currently participating in a Marquette sport or activity? *
What sport or activity are they currently participating in?
When was the last time the student was at an official Marquette Catholic function such as practice/game or activity outside of regular school hours?
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Outside of official Marquette Catholic events, when was the last time the student was around other Marquette students? Please describe the location and context of the event. *
Regarding the question above, outside of school hours, please list all the Marquette Catholic students the student has been around and the location where they were around these other  (work, gathering, sport/activity) *
On what date, and what time of day, did the student's symptoms begin?
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Time
:
Please check any symptoms the student has had in the last 14 days *
Required
Has anyone in the household where the student lives tested positive for the virus? *
Required
If someone in the same household as the student has tested positive, please provide the date of their test (not the date they received results but the day they actually received the test)
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If someone in the same household as the student has tested positive, please provide the date that person first began to experience symptoms of the virus.
If you have any other information please provide it in the space below.
A copy of your responses will be emailed to the address you provided.
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