STUDENT: COVID-19 Symptom Screening Questions
COVID-19 Symptom Screening Questions for Hybrid/In-Person Learning Students Only
REVISED: January 15, 2021
Student’s First Name *
Student’s Last Name *
Grade Level *
In the last 10 days, have you tested positive for COVID-19 or are you waiting for results of a COVID-19 test? *
The CDC defines Close Contact as “any individual who was within 6 feet of an infected person for at least 15 minutes over a 24-hour period, starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection) until the time the patient is isolated.”
In the last 7 days, have you had Close Contact with anyone or live in the same household with anyone confirmed to have COVID-19 or waiting for results of a COVID-19 test? *
In the last 7 days, have you experienced, or are you currently experiencing, any new or unusual symptoms not experienced before as follows: *
If you answered YES to any of these questions you cannot enter any district facility. Immediately advise your School Principal and do not report to the school building. Your School Principal will contact you for further review and return to school instructions.
Never submit passwords through Google Forms.
This form was created inside of Savannah Chatham Public School System. Report Abuse