Daily Health Check In Form
In order to keep everyone safe and healthy, all parents/guardians must fill out this this form prior to their child(ren) entering the building each day.
The purpose of this screening is to provide a safe learning environment for all as well as contact tracing in the event of a possible Covid-19 infection. It is designed to assist in tracing and limit the spread of the virus.
You must fill out one form for child you are sending to school.
Please answer accurately.
Keep in mind that if you are exposed to COVID-19 symptoms may appear 2-14 days after exposure to the virus.
Remember to send your child in their mask every day.
If your child is sick or has any of the below listed symptoms, please keep them home.
By submitting this form, I confirm that the information on this form is true, complete, and accurate. Further, I understand that my willful misrepresentation may place children and adults at risk.
First and Last Name of Adult Completing this Form* * This form must be completed by the parent or guardian. Students should not be completing this form.* *
First/ Last Name of Student and grade level this form is being completed for.
If any of the fields in this Section are checked off, please keep your child home and notify the school for further instructions.
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
None of the above
Have you had close contact (less than 6 feet for fifteen minutes or more) with a person with COVID-19 ?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Newark Educators' Community Charter School.