DBHS Academic Stable Groups Health Screening Log
THIS FORM IS TO BE COMPLETED BY THE PARENT OR GUARDIAN OR BY THE DBHS STAFF MEMBER WHO IS RESPONSIBLE FOR SCREENING THE VISITOR. STUDENTS MAY NOT COMPLETE THIS FORM. The responsible person completing this form enters their name on the first question.

All persons are required to complete a health screening, prior to entry to any WVUSD property, by answering the questions below. This Screening is vital to ensure the health and well-being of each person on our WVUSD sites. Students will not not be allowed to enter a WVUSD worksite if they answer YES to any of the health screening questions.

1) Is the student experiencing any of the following symptoms: Current or recent fever (100.4° or higher), chills, new cough (above baseline), diarrhea, vomiting or nausea, shortness of breath, difficulty breathing, muscle or body aches, or new loss of taste or smell?
2) Is the student currently under a quarantine or isolation order?
3) Within the last 14 days, has the student been in close contact with any person who has tested positive with COVID-19, or who has symptoms of illness that may be consistent with possible COVID-19?
4) Within the last 14 days, has the student or anyone in the student's household traveled outside of California?
5) Is the student currently waiting for the results of a COVID-19 test?


**CLOSE CONTACT is defined as: Being within approximately 6 feet of a COVID-19 case for 15 minutes or more; close contact can also occur when having direct contact with infectious secretions of a COVID-19 case (being coughed on).
ENTER the name of the person completing this form (Must be Parent/Guardian or DBHS Staff Member - No Students) *
Student Last Name *
Student First Name *
Student ID# (6-digit number)
What is the reason for visit? *
Location on campus to be visited *
1) Is the student experiencing any of the following symptoms: Current or recent fever (100.4° or higher), chills, new cough (above baseline), diarrhea, vomiting or nausea, shortness of breath, difficulty breathing, muscle or body aches, or new loss of taste or smell? *
2) Is the student currently under a quarantine or isolation order? *
3) Within the last 10 days, has the student been in close contact with any person who has tested positive with COVID-19, or who has symptoms of illness that may be consistent with possible COVID-19? *
4) Within the last 10 days, has the student or anyone in the student's household traveled outside of California? *
5) Is the student currently waiting for the results of a COVID-19 test? *
***If you answered YES to any of the health screening questions above, please explain
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