Health Questionnaire Screening
This form must be completed each day before entering the school.
Let's Work Together and Stay Healthy
Cell Number *
Last Name *
Name of family member(s) entering the building *
For children only....has the child taken any medicine that reduces fever in the last 24 hours? *
Has anyone listed on this form experienced any of the following symptoms that indicate a possible COVID-19 infection? Temperature of 100.4 degrees Fahrenheit or higher when taken by mouth; a new loss of taste or smell; sore throat; new uncontrolled cough that causes difficulty breathing (or, for students with a chronic allergic/asthmatic cough, a change in their cough from baseline); diarrhea; vomiting or abdominal pain; new onset of severe headache, especially with a fever? *
Have you had close contact with anyone who is lab-confirmed with COVID-19 in the last 14 days? Close contact is defined as: *Being directly exposed to infectious secretions (e.g., being coughed on); or *Being within 6 feet for a cumulative duration of 15 minutes; If either occurred at any time in the last 14 days at the same time the infected individual was infectious." *
Never submit passwords through Google Forms.
This form was created inside of Bear Creek UMC Church School. Report Abuse