Wellness Self Assessment
This form is designed for students to report their self screening for potential illness symptoms. *IF THE ANSWER IS "YES" TO ANY OF THE FOLLOWING QUESTIONS, STUDENTS SHOULD NOT ATTEND ACTIVITIES ON THAT DATE. STUDENTS WILL NEED TO REMAIN HOME FOR 3 DAYS AND GAIN A DOCTORS NOTE TO RETURN TO ACTIVITY FOR A FEVER OVER 100.*
Email address *
Last name *
First name *
Date: *
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YYYY
Program *
Temperature is Over 100 degrees *
Fever or chills *
Cough *
Nasal Congestion or Runny Nose *
Sore Throat *
Shortness of Breath or Difficulty Breathing *
Dairrhea *
Nausea or Vomiting *
Fatigue *
Headache *
Muscle or Body Aches *
New Loss of Taste or Smell *
In the past 14 days, have you traveled to or returned from any of the CT Travel Advisory states? For a full list, please use this link. https://portal.ct.gov/Coronavirus/Covid-19-Knowledge-Base/Travel-In-or-Out-of-CT *
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