Vejar Health Screen Form
A health screening must be completed by the parent before dropping off the student to class.
Student Last Name 學生姓
Student Last Name 學生名
Student ID# 學生號#
Student: Are you experiencing any symptoms such as current or recent fever (100.4° or higher), chills, cough, shortness of breath or respiratory illness, sudden lack of taste or smell, or sudden onset of unexplained gastrointestinal illness? * 學生 ：您現在或最近是否有以下症狀，發燒（100.4°或以上），發冷，咳嗽，呼吸急促或呼吸道疾病，失去味覺或嗅覺，或有突發的無法解釋的胃腸道疾病？ *
Student: Have you been in close contact** with any person who has been infected with COVID-19 or suspected to be positive with COVID-19 within in the last 14 days? ** CLOSE CONTACT is defined as: Being within approximately 6 feet of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case or having direct contact with infectious secretions of a COVID-19 case (being coughed on). * 學生：在過去的14天內，您是否有密切接觸到感染了COVID-19的人？ **密切接觸的定義為：與COVID-19病例在6英尺的範圍内長時間相處； 密切接觸也可發生在照顧，一起居住，探訪，或與COVID-19病例一起在醫療候診區或房間時，或直接接觸到COVID-19病例的傳染性分泌物（咳嗽）。*
Are you currently waiting for the results of a COVID-19 test? 您当前是否在等待 COVID-19 测试结果？
If you have answered "yes" to the previous two questions, please do not enter the school site, return home, and contact the coordinator Mrs. Elisabeth Jones firstname.lastname@example.org to report your child's absence. 如果您對前兩個問題有回答“是”，請不要進入校區，請返回家中，並與負責人Mrs. Elisabeth Jones email@example.com 聯繫。
Parent/ Guardian 家長/監護人:
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This form was created inside of Walnut Valley USD.