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
Sign in to Google to save your progress. Learn more
Last Name of child *
First Name of child *
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? * *
Shortness of breath or difficulty breathing
Fever or chills
Muscle or body aches
Sore throat
Nausea or vomiting
Runny nose or stuffy nose
Recent loss of taste or smell
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 ? * *
Has this child traveled anywhere outside the 50 United States in the past 14 days? * *
Is this child within a quarantine or isolation period directed by the RI Department of Health or a healthcare provider? * *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Middletown Public Schools. Report Abuse