Divine Wisdom Catholic Academy
Health Screening for COVID-19
Parents, please fill this out this form if you plan on coming into the main office for ANY reason.
For Volunteers, fill out the form on the tablet on the security desk instead.
NOTE: This is NOT the health screening for in-person students.
* Required
Email
*
Your answer
Your Name and/or Children
*
Your answer
Cell Phone Number with Area code
*
Example: 7186313153
Your answer
Reason for Visit
*
Your answer
Elevated body temperature greater than 100 degrees
*
1 point
Yes
No
Coughing/Sore Throat
*
1 point
Yes
No
Shortness of Breath or Difficulty Breathing
*
1 point
Yes
No
Nausea, Diarrhea, Vomiting
*
1 point
Yes
No
New loss of taste or smell
*
1 point
Yes
No
Fever Reducer Medication has been administered
*
1 point
Yes
No
Has you or anyone in your home traveled outside of New York State (domestic or internationally)in the last 14 days? Please check the list of commonwealth/states/districts that are on the New York self-quarantine list.
https://coronavirus.health.ny.gov/covid-19-travel-advisory
*
1 point
Yes
No
Knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19?
*
1 point
Yes
No
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