Daily Health Attestation - Giving Tree School
Please complete for each day your child attends school. If you answer yes to any of the following, do not bring child to Giving Tree, and please call or text to notify us - 413-768-2450.
* Required
Name of Child
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
Best contact number today
*
Your answer
Have you observed any of the following symptoms in your child or another household member during the past 24 hours?
Fever of 100.0 degrees Fahrenheit or higher?
*
Yes
No
Cough?
*
Yes
No
Sore Throat?
*
Yes
No
Rapid breathing or difficulty breathing (without recent physical activity)?
*
Yes
No
Gastrointestinal symptoms (diarrhea, nausea, vomiting)?
*
Yes
No
Fatigue (fatigue alone should not exclude a child from participation)?
*
Yes
No
Headache?
*
Yes
No
New loss of smell or taste?
*
Yes
No
New muscle aches?
*
Yes
No
Any other sign of illness?
*
Yes
No
Within the last 14 days, have you or your child had close contact with a COVID-19 positive individual?
*
Yes
No
Please list where your child has been (excluding their primary residence) since they were last at Giving Tree.
*
Your answer
If you answered "yes" to any of the above questions, do not bring child to school, and call or text to notify us: 413-768-2450.
If you have questions about whether it is appropriate to return to school, please refer to our quick reference flowchart for symptoms of illness:
https://drive.google.com/file/d/1bQ0L-w6lnqYqA6hPb3jw8iQWeB_oJNqh/view?usp=sharing
Parent/guardian signature
*
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
