Student Daily Health and Safety Screening Form
This form must be submitted prior to entering the Quogue School each day.

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Student Last Name *
Student First Name *
Student Grade *
COVID Symptom Checker
Temperature above 99.99 degrees Fahrenheit
Unexplained cough
Unexplained shortness of breath
Unexplained chills
Unexplained fatigue
Unexplained muscle aches
Unexplained sore throat
Unexplained headache
Unexplained new loss of taste or smell
Unexplained Nausea
Unexplained vomiting
Unexplained diarrhea
Unexplained congestion or runny nose
Do you have any of the unexplained symptoms listed above? *
Have you been exposed to COVID-19 in the last 10 days? *
Have you traveled internationally from a country with widespread community transmission of COVID-19 per the NYS Travel Advisory, in the past 10 days? *
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