Daily Student Screening Form MPS
Please fill out this form each day when planning to send your child to IN PERSON school. This is a declaration form shared with our school nurses and administration that attests to your child's health and non-risk factors for school attendance. If a child is not able to come to school today she/he can always remote learn from home.

If you answer "YES" to any of the questions below and cannot explain these symptoms by known allergies or non-infectious illness, then your child cannot come to school. Please reach out our school nurses for more help and assistance.

This form is automatically date/time stamped for each day of submission.
You must complete a form for each child.
* Required
Last Name of child
First Name of child
SCHOOL
Clear selection
GRADE
Clear selection
Has this child had any of the following symptoms in the past three days that are NOT explained by allergies or a non-infectious cause? *
YES
NO
Cough
Shortness of breath or difficulty breathing
Fever or chills
Muscle or body aches
Sore throat
Headache
Nausea or vomiting
Diarrhea
Runny nose or stuffy nose
Fatique
Recent loss of taste or smell
Row 2
Row 3
Clear selection
Has this child been in close contact (less than six feet) with anyone with Covid-19 or symptoms of Covid-19 in the past 14 days ? *
Clear selection
Has tis child travelled anywhere outside the 50 United States in the past 14 days? *
Clear selection
Is this child within a quarantine or isolation period directed by the RI Department of Health or a healthcare provider? *
Clear selection
Submit
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