Daily Health Screening Questionnaire - Grade 4
Parents: Please complete this short check each schoolday morning and report your child’s information in the morning before your child leaves for school.
If the answer is YES to any question, please DO NOT bring your child to school and contact your medical professional. (Revised 09/08/2021)
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Email *
Student *
This Daily Heath Screening is required to be completed each day before entrance to school.
1. Is your child, or a household member currently waiting for the results of a COVID-19 test? *
2. In the past 10 days, Has your child experienced any symptoms of COVID-19 , including a fever of 100.0 F or greater, new cough, loss of taste or smell, shortness of breath, sore throat, headache, nasal congestion, runny nose (sniffles), stomach upset? *
3. In the past 10 days has your child gotten a lab confirmed positive COVID-19 test result (not a blood test) that was their first positive COVID-19 result OR was 90 days from their previous positive COVID-19 result? Please note the 10 days is measured from the day you were tested, not the day you received the results. *
4. To the best of your knowledge, in the past 10 days has your child been in close contact (within 6 feet for at least 10 minutes over 24 hour period) with anyone who has tested positive for COVID -19 or who has been told they have symptoms of COVID-19 ? *
5. In the last 10 days has your child or a household member returned from an international destination? *
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This form was created inside of St. Michael's Catholic Academy. Report Abuse