Mrs. Zanger's Student Certification Form

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Christ the King School requires self-certification and verification for all staff, students, and visitors entering our school building.

Conduct a daily temperature and symptom checks on your child before leaving your house and certify your answers by filling out the form below.

Individuals who have a temperature of 100.4 degrees Fahrenheit or one of the symptoms listed below may not enter the Christ the King School Building.

Individuals who exhibit symptoms will be sent home and referred to a medical provider for evaluation and treatment.

Date: *

YYYY

Name of student: *

Print Name of Adult Certifying Symptom Check: *

Temperature of student *

Did you give your child any type of over the counter medication this morning? *

Yes

If yes, what time was medication given?

If yes, what type of over the counter medication given and reason for giving?

Symptoms *

None of the symptoms listed below are present

Symptoms are present, I indicated which symptoms on the list below

A doctor's note to the school has been provided certifying that my child's cough is asthma related or that my child's cough/runny nose/congestion is allergy related

Required

Select Yes if a symptom is present or No if not present

Yes

Temperature greater or equal to 100.4 degrees

New onset of moderate to severe headache

Shortness of Breath

New Cough

Sore Throat

Vomiting

Diarrhea

New loss of taste or smell

Fatigue from an unknown cause

Muscle or body aches from an unknown cause

Runny nose

Congestion

Clear selection

Submit

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