MDUSD Daily Student Health Form

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MDUSD Daily Student Health Form - Zappettini

Dear Families,
Please fill out the following check-in form every day before bringing your child to campus for in-person instruction. If you answer yes to any of the following questions, please follow up with your child's principal immediately. This form needs to be filled out for each student attending in-person instruction.
Thank you!
---Your Principal

Student ID# * *

First Name *

Last Name *

Grade Level *

Is your child experiencing any symptoms such as current or recent fever (100.4 degrees or higher), new or worsening cough, new or worsening shortness of breath or respiratory illness, sudden lack of taste or smell, sudden onset of unexplained gastrointestinal illness? * *

Yes

Have you been in close contact with anyone who has been diagnosed with COVID-19? * *

Yes

Have you been in close contact with anyone who is experiencing symptoms of COVID-19, but is yet to be confirmed? * *

Yes

Are you living with, or in close contact with, anyone such as a family member who is experiencing symptoms or has been confirmed as positive for COVID-19? *

Yes

Have you traveled outside of the continental United States within the past 14 days? *

Yes

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