Student Health Screening Form
Parents/Guardians must complete prior to student arrival.
One form must be completed for each person.
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Email *
Student's Last Name *
Student's First Name *
Block 1 Teacher Name *
Student Temperature reading taken this morning prior to school
Symptoms
Column A Symptoms: If TWO OR MORE of the symptoms in Column A are checked off please keep your child home and notify the school for further instructions.
**Please note that anyone with a fever, vomiting, or diarrhea should stay home until 24 hours free of fever, vomiting, and diarrhea.
Within the past 24 hours, has your child experienced any of the following symptoms?
Column B Symptoms: If AT LEAST ONE symptom in column B is checked off, please keep your child home and notify the school for further instructions.
Column B Symptoms: Within the past 24 hours, has your child experienced any of the following symptoms?
Close Contact / Potential Exposure: If you mark "Yes" for any of the 3 questions below, contact your school nurse for exclusion requirements before entering a school building.
Has your child had close contact (within 6 feet for at least 15 minutes in a 24 hour period) with an individual with COVID-19?
Clear selection
Is someone in your household diagnosed with COVID-19, or excluded from work/school due to Covid-compatible symptoms?
Clear selection
In the past 10 days, has your child spent more than 24 hours in a state or country outside of NJ, NY, PA, CT, or DE?
Clear selection
Is your child ordering lunch today? *
Thank you for completing this screening form!
A copy of your responses will be emailed to the address you provided.
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