Student Health Screening Form
Parents/Guardians must complete prior to student arrival.
One form must be completed for each person.
Email address *
Student's Last Name *
Student's First Name *
Block 1 Teacher Name *
Student Temperature reading taken this morning prior to school *
Symptoms
Column A Symptoms: If TWO OR MORE of the symptoms in Column A are checked off please keep your child home and notify the school for further instructions.
Within the past 24 hours, has your child experienced any of the following symptoms? *
Required
Column B Symptoms: If AT LEAST ONE symptom in column B is checked off, please keep your child home and notify the school for further instructions.
Column B Symptoms: Within the past 24 hours, has your child experienced any of the following symptoms? *
Required
Close Contact / Potential Exposure: If you mark "Yes" for any of the 3 questions below, your child should remain home for 14 days from the last date of exposure (if child is a close contact of a confirmed COVID-19 case) or date of return to New Jersey.
Has your child had close contact (within 6 feet for at least 15 minutes in a 24 hour period) with a person with confirmed COVID-19? *
Is someone in your household diagnosed with COVID-19? *
Has your child traveled to an area of high community transmission? *
Quarantine Information
Is your child currently under quarantine? *
If your child is under quarantine, what is the date that your child started quarantine?
MM
/
DD
/
YYYY
In the past 2 weeks, has your child traveled from a state or country outside of NJ that has a travel advisory requiring quarantine? *
If you've answered yes to any of these questions, keep your child home, notify your school nurse and consult with your health care provider.
Will your child be traveling to school on their school bus today? *
Thank you for completing this screening form!
A copy of your responses will be emailed to the address you provided.
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