Student COVID-19 Screening Checklist and Parent Acknowledgment
Please keep this checklist readily available for daily assessment of your child.
In order to protect your child’s health as well as the Freehold Borough Community, it is imperative that you evaluate your child each morning prior to coming to school. Below is a list of common COVID symptoms to assist you in evaluating your child’s health.

Please keep your child home if the checklist indicates the possibility of illness and follow up with your physician. Please contact the nurse with any concerns or questions.

Section 1: Symptoms: Any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child daily for these symptoms:
Email address *
Name of Child attending Freehold Borough School District: NOTE: If you have more than 1 child in the district you must complete a separate form for each child. *
School *
Grade of Child who is attending Freehold Borough School District: Note if you have more than 1 child in the district you must complete a separate form for each child. *
If TWO OR MORE of the fields are checked off, please keep your child home and notify the school for further instructions. **Please note that anyone with vomiting or diarrhea should stay home until 24 hours free of vomiting/diarrhea.
Clear selection
If ONE field is checked off, please keep your child home and notify the school for further instructions.
Clear selection
Section 2: Close Contact/Potential Exposure: If ANY of the fields are checked off, your child should remain home for 14 days from the last date of exposure (if the child is in close contact of a confirmed COVID-19 case) or date of return to New Jersey. Contact your child’s provider or your local health department for further guidance. - Please Verify if:
Clear selection
Covid Screening Acknowledgement: - Parents/Guardians, I acknowledge receipt and have reviewed the COVID Screening checklist and understand that it is my obligation to protect the school community from spreading COVID-19 by assessing my child daily. Accordingly, I will: Assess my child’s health for all symptoms listed on the assessment tool each day prior to sending my child to school. Report any student/family travel to areas of high transmission as per the NJDOH advisory· I acknowledge that am required to quarantine my child/family for 14 days following travel to an area of high community transmission as updated by the NJDOH NJDOH travel advisory link: https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey *
MM
/
DD
/
YYYY
Parent/Guardian: Full Name *
Submit
Never submit passwords through Google Forms.
This form was created inside of Freehold Borough Schools. Report Abuse