QEA Scholar Health Attestation Form - COVID 19 Screening
Any scholar entering QEA facilities, such as a school building or transportation vehicle, must be screened for COVID-19 symptoms and have their temperature checked daily. This form is used at the discretion of QEA. If you are the Parent/Guardian of multiple scholars, a separate form must be submitted for each scholar. Scholars cannot return to in-person instruction until this form is submitted. Thank you for your assistance.
(Todo estudiante antes de entrar o usar cualquier propiedad de QEA, tales como cualquier edificio o vehículo de trasporte, deberá estar libre de síntomas de COVID-19 y se le tomará la temperatura. QEA se reserva el derecho de usar esta información a discreción. Si usted tiene más de un estudiante en QEA deberá completar esta forma por cada estudiante por separado. Todo estudiante deberá completar esta forma antes de volver a la escuela de forma presencial. Le agradecemos de antemano su colaboración.)
Scholar's Name (Nombre del estudiante): *
Scholar's Grade (Grado): *
Does your scholar have any of the below symptoms? (Tiene Ud. Alguno de los siguientes síntomas?) *
Required
Please check any that may apply (Por favor marque la casilla que corresponda): If any of the first four boxes are checked, you will be contacted by a School Official at your phone number listed below *
Required
NOTE: Look for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately: Trouble breathing; Persistent pain/pressure in chest; New confusion; Inability to wake or stay awake; Blush lips or face. This emergency warning signs list is not a list of all possible symptoms. Contact your medical provider for symptoms that are severe or concerning. (En caso de presentar alguno de estos síntomas proceda a hacerse una prueba inmediatamente o busque asistencia médica.)
Parent/Guardian Name (Firma del Padre o Representante): *
Parent/Guardian Phone Number (Número de teléfono del padre): *
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