COHS Daily COVID-19 Health Questionnaire
Name (First, Last) *
Contact Phone Number *
Grade Level *
Have you tested positive for COVID-19 in the past 10 days? *
Have you had contact with anyone confirmed or suspected of having COVID-19 in the past 10 days? *
For the questions below, please indicate if you are experiencing any of the following symptoms:
Fever and/or chills *
Shortness of breath or difficulty breathing *
Fatigue and/or Headache *
Cough, Sore Throat, Congestion and/or Runny Nose *
Muscle Aches *
Nausea, Vomiting, or Diarrhea *
New loss of Taste and/or Smell *
If you answered yes to any of the above question, please stay home, DO NOT ENTER THE BUILDING, You will be contacted by a staff member. Thank you for taking the Daily COVID-19 Survey
Submit
Never submit passwords through Google Forms.
This form was created inside of Cardinal O'Hara High School. Report Abuse