CHS Daily Screening Form
Please fill out this form honestly to ensure the health of our students and staff.
Student Name
Has he/she developed ANY of the following symptoms of COVID-19 infection in the last 10 days?
Has any members of the household developed ANY of the following symptoms of COVID-19 infection in the last 10 days?
Has the student or any member of the household had a POSITIVE test for Covid-19 infection within the past 10 days?
Clear selection
Within the last 10 days, has the student or any member of the household been within 6 feet, or longer than 15 minutes with someone who has a suspected or confirmed Covid-19 infection WITHOUT taking precautions such as wearing a mask and frequently washing hands during this contact period?
Clear selection
Has anyone within the family or household traveled out of state in the past 10 days? If yes please write where in the "other" option
Clear selection
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