Trinity COVID-19 Screening

Child's First Name *

Child's Last Name *

In the previous 14 days have you or your child had contact with someone with a confirmed diagnosis of COVID-19? *

Yes

No

In the previous 14 days have you or your child had contact with someone who is under investigation for COVID-19; or is ill with a respiratory illness? *

Yes

No

In the previous 14 days have you or your child traveled internationally to countries with widespread, sustained community transmission (China, Europe, Iran, Ireland, Malaysia,South Korea or the United Kingdom: England, Scotland, Wales, and Northern Ireland)? *

Yes

No