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CCSC Covid-19 Student Symptom Screener
This form is to be filled out AFTER your return to school has been approved by building administration.
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* Required
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Today's Date
*
Ex. 02/01/2021 (MM/DD/YYYY)
MM
/
DD
/
YYYY
Student's School
*
CHS
CMS
Hoover Elementary
Nicholson Elementary
Hose Elementary
Willson Pre-K
Other:
Has the student experienced any of these symptoms in the last 24 hours?
*
Fever or Chills
Cough
Shortness of Breath
Fatigue
Headache
New Loss of Taste or Smell
Sore Throat
Congestion or Runny Nose
Nausea or Vomiting
Diareaha
Body or Muscle Aches
No Symptoms in the last 24 hours
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