AUSD Student and Visitor COVID-19 Health Screening Form
Please complete the form and then select the option to "view score" at the end. Feedback and next steps will be provided.



This form is designed to identify possible symptoms of COVID-19 and/or other potentially contagious illnesses.

By submitting this form you are attesting that the following information is true and that to your knowledge you are not experiencing any signs of potentially contagious illness. Please note that it is the recommendation of AUSD Health Services that you not attend school/school-sponsored events if you have symptoms or could possibly spread contagious illness.

This form has been adapted from the LA County Department of Public Health's COVID-19 Reopening protocols. This form does not constitute medical advice and is for screening purposes only.
Email address *
Please write your full name *
In the past 10 days have you/your student experienced any of the following symptoms: *
1 point
Required
In the last 10 days, has anyone in your/your student's household(s) experienced any of the above symptoms? *
1 point
In the last 10 days, have you/your student or anyone in your student's household(s) had contact with a confirmed or suspected case of COVID-19? *
0 points
A copy of your responses will be emailed to the address you provided.
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