Daily Pre-screening Questionnaire for Charlton Middle School Students
As part of the opening of school each staff and student must self certify (every school day) to the public health and Covid related questions below.
Student First Name:
Student Last Name:
Have you/child been in close contact (less than 6ft for more than 15 minutes) with anyone that has tested positive for COVID-19 in the past 14 days?
Have you/child experienced any of these symptoms in the last 24 hours? *Please identify all symptoms that you have/are experiencing*
Fever and chills
Signs of lower respiratory illness (cough, shortness of breath)
Runny nose or congestion
New loss of sense of taste or smell
Other less common gastrointestinal symptoms (i.E. nausea, vomitting, diarrhea)
I have NOT experienced any of the above symptoms
If you traveled out of state, please read the Massachusetts Travel Advisory (
). We need to keep COVID out of our schools, so please follow the advisory if you or your children traveled and have any symptoms
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This form was created inside of Dudley-Charlton Regional School District.