Daily Student COVID-19 Symptom Assessment
This form needs to be submitted every day your child attends school. Please check YES or NO if any of the following pertain to your child’s health since the last day of school. One form for each child, please.
Student Grade *
Student Name *
Does your child have: *
Yes
No
Fever 100.4 degrees or greater?
Cough, sore throat, or difficulty breathing?
Headache?
Chills or muscle or body aches?
Nausea, vomiting, or diarrhea?
Unexplained rashes or blister-like sores on the skin?
Sudden loss of taste or smell?
A family member or close contact with any of the above symptoms?
Has your child been in close contact with anyone diagnosed with COVID-19 or anyone who has been placed in quarantine for possible exposure of COVID-19?
Has your child or anyone in your family been asked to self-isolate¹ or quarantine by a medical professional or local public health official?
Has your child/family recently traveled to or from an area with increased cases/spread of COVID-19?
NOTE: ¹Self-isolation is defined by having been in a high risk situation, such as exposure to someone who has a confirmed COVID 19 diagnosis. Quarantine is defined by a person who has COVID 19 or has symptoms and is awaiting test results.
If you have answered YES to any of the above screening questions, please DO NOT send your child to school. Please contact a healthcare provider for further direction and guidance.
If you answered NO to all the questions, send your child to school with their face covering, this completed self screening sheet and reminders to socially distance and wash their hands.
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