Daily Health Screen | CTC
Falsifying information or willfully withholding information essential to the safe operation of a PACCC program may result in termination of child care services.

If the answer to any of these questions is yes, you must STAY HOME and seek medical care.

Effective 11/30/20 all persons traveling into Santa Clara County, by any means, directly or indirectly from a point of origin greater than 150 miles from the County's borders must quarantine for 10 days upon arrival.
Date form is being submitted for *
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Child's Full Name *
Child's Current Temperature *
Have you or your child had any one or more of the following symptoms today or within the past 3 days? .......... Fever at or above 100° F by any method •• Repeated shaking and/or chills •• Shortness of breath or difficulty breathing •• New loss of taste or smell •• Cough *
Have you or your child had any one or more of the following symptoms today or within the past 3 days and that are NEW or NOT EXPLAINED BY ANOTHER REASON? .......... Fatigue •• Muscle or body aches •• Headache •• Sore throat •• Nausea/vomiting/diarrhea *
Within the last 10 days, have you or your child been diagnosed with COVID-19 or had a test confirming you have the virus? *
Within the last 10 days, have you or your child had close contact with someone who has been in isolation for COVID-19 or had a test confirming they have the virus? Close contact is less than 6 feet for 15 minutes or more. *
Have you or your child traveled over 150 miles in the last 10 days? *
Electronic Signature Consent
By clicking the submit button below, you declare that the information you have provided is true and that you have answered NO to all of the above questions.
Parent/Guardian's Electronic Signature *
Please type your full name.
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