COVID SCREENING FORM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

All students are required to complete every week the Online Screening Form in order to be enter our school.

Today's date *

YYYY

Student last and first name (One form per each student please) *

Have you (the student) or ANYONE in your household had any of the following symptoms in the past 7 days? Fever and/or Chills / Running nose / Cough / Congestion / Difficulty breathing/ Sore throat / Nausea / Vomiting / Diarrhea / Loss of taste and/or smell / Body aches / Muscle pain * *

Yes

Have you (the student) or ANYONE in your household been diagnosed with COVID-19 or been exposed to anyone with COVID-19 in the past 7 days?* *

Yes

I understand that the information I have given is correct to the best of my knowledge (person who is filling the form need to type their name here) *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms