Student COVID-19 Self-Assessment
This form must be complete prior to returning to campus every morning. One form per child.
First & Last Name
What grade are you in?
Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days?
In the last 48 hours, have you had any of the following NEW symptoms? Check all that apply.
Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating
Trouble breathing, shortness of breath or severe wheezing
Chills or repeated shaking with chills
Loss of smell or taste, or a change in taste
Nausea, vomiting or diarrhea
None of the above
Has a public health official advised you to get tested for COVID-19?
If you are feeling ill it is your responsibility to report it to the administration. By doing so, you are keeping our community safe.
I understand and will report if I feel ill to the Administration.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Holy Cross of San Antonio.