COVID-19 Daily Health Screening Form 2021
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Email *
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Date *
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Student's Last Name , First Name *
Symptoms 1 *
Any of the symptoms below could indicate a COVID-19 infection and may put your child at risk for spreading the illness to others. Please note that this list does not include all possible symptoms, and individuals with COVID-19 may experience any, all or none of these symptoms. Please check your child for these symptoms daily. If you checked two or more symptoms in this section, please notify school administration and stay home until further notice.
Required
Symptoms 2 *
Any of the symptoms below could indicate a COVID-19 infection and may put your child at risk for spreading the illness to others. Please note that this list does not include all possible symptoms, and individuals with COVID-19 may experience any, all or none of these symptoms. Please check your child for these symptoms daily. If you checked one or more symptoms in this section please notify school administration and stay home until further notice.
Required
Close Contact/Travel *
If ANY fields in this section are checked, and your child is not fully vaccinated (2 weeks past 2nd vaccine), your child should remain home for 10 days from the last date of exposure or date of return to New Jersey. If someone in your household is ill, and your child is not fully vaccinated, your child should quarantine at home from now until 10 days after the symptomatic individual completes their 10 days of isolation or has a negative Covid Test. Please visit covid19.nj.gov for the current list of high community transmission. Contact your school administrator for further instructions.
Required
Vaccination Status
The student has been fully vaccinated for Covid-19 (2 weeks have passed since their final dose of the complete series). Vaccinations are not required for school entry but are helpful in determining appropriate response.
Parent Last Name, Parent First Name *
Cellular Number
Pease enter the best number to reach you should your child be symptomatic or need to quarantine for close contact/travel.
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