Temperature & Health Questionnaire Screening
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our community, we are conducting a simple screening prior to your child's in-person schoolday. Your participation is important to help us take precautionary measures to protect our community. We request you complete this screening for each child in your home before sending them to the school buidling each day.
1. TRAVEL RESTRICTIONS HAVE CHANGED - PLEASE REVIEW THE LINK FOR NEW INFORMATION
Have you traveled internationally or to a state or US territory with widespread community transmission of COVID-19 per the NYS Travel Advisory? Visit
2. Have you been in close contact (within 6 feet for 10+ minutes) with someone who has a confirmed case of COVID-19 or has exhibited symptoms of COVID-19?
3. Are you currently experiencing any of the following symptoms?
a. Fever (greater than 100.0°F) or the chills
c. Shortness of breath or difficulty breathing
e. Muscle or body aches
g. New loss of taste or smell
h. Sore throat
i. Congestion or runny nose
j. Nausea or vomiting
Student Name (Last Name, First Name)
Student's Grade Level
Has your child been tested for COVID - 19 in the last 72 hours?
I hereby agree to partner with the school to pre-screen my child(ren) prior to the start of each school day. I understand that if my child displays any COVID-19 symptoms or have answered yes to any of the questions above, they cannot attend school. I am also aware that the school will screen students for elevated body temperature upon their arrival at school. If my child(ren) at that time has a temperature greater than 100.0F or displays any symptoms of COVID-19 throughout the school day, our school nurse will reassess them and follow our established protocol and procedures.
My child is symptom free and ready for the school day!
We will not be sending my child to school today.
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This form was created inside of Westfield Academy Central School.