K-4 SCHOOL SYMPTOM SCREENING: PARENT/GUARDIAN ATTESTATION For any individual who cannot accurately respond for themselves
Upon entry to school, the screener must direct the questions below to the accompanying
individual who can respond accurately on behalf of the person . If the answer is “yes”
to any of the questions below, that individual must be excluded from school .
For more detailed steps on how to respond to a “yes” on any of the questions below, screeners and school leaders
should refer to the Reference Guide for Suspected, Presumptive, or Confirmed Cases of COVID-19 .
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Grade Level
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KINDERGARTEN
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
Teacher's Last Name
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Your answer
Child's First Name:
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Your answer
Child's Last Name:
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Your answer
Parent/Guardian First Name:
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Your answer
Parent/Guardian Last Name:
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Your answer
Parent/Guardian Phone Number:
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Your answer
Has the individual you are dropping off been diagnosed with Covid-19 since they were last at school?
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Yes
No
• If No, move on to Question 3.
• If Yes, say and ask: They cannot go to school .
(ONLY ANSWER THIS QUESTION IF YOU ANSWERED 'YES' TO THE PREVIOUS QUESTION) Does anyone else who lives with them also go to or work at this school?
Yes > Those individuals cannot go to school
No
Clear selection
Has the individual you are dropping of had any of the following symptoms since they were last at school?
Fever
Chills
Shortness of breath or difficulty breathing
New loss of taste or smell
New Cough
• If No, move on to Question 5.
• If Yes, say and ask: They cannot go to school .
(ONLY ANSWER THIS QUESTION IF YOU ANSWERED 'YES' TO THE PREVIOUS QUESTION) Does anyone else who lives with them also go to or work at this school?
Yes > Those individuals cannot go to school
No
Clear selection
Has the individual you're dropping off had close contact (between within 6 feet of someone diagnosed with COVID-19 for a commutative total of 15 minutes over a 24 hour time period) in the last 14 days?
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Yes
No
• If No, move on to next.
• If Yes,say: They cannot go to school .
Has any health department staff or a health care provider been in contact with the person you are dropping off and advised them to quarantine?
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Yes > The child should not be at school. The child can return 14 days after the last time he or she had close contact with someone with COVID 19, or as listed below.
No > The child can be at school if the child is not experiencing symptoms
• If No, The person may go to school
• If Yes,say: They cannot go to school .
I attest that the following information is true to the best of my knowledge as of :
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MM
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DD
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YYYY
First Name
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Your answer
Last Name
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Your answer
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