Mayfield CSD - COVID-19 Student Screening
All students must complete this form weekly when they are in the district.

1) Do you currently have any of the following COVID-19 symptoms?
• 100.0+ degree temperature
• cough
• shortness of breath
• chills
• sore throat
• new loss of smell or taste
• nausea/vomiting/diarrhea

2) Are you under mandatory or precautionary quarantine for COVID-19?

3) In the last 14 days, have you participated in a mass gathering (100 or more people)?

4) In the last 14 days, have you travelled to any of the designated hot spot states?

5) In the last 14 days, have you come into close contact with another person known to be positive or a person who is awaiting test results for COVID-19?
Student Name *
Building: *
Answer to above questions *
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