ICD Daily Child Health Questionnaire
Please complete this form prior to your child's arrival to ICD. This information is required as part of our adherence to the New York State Department of Health (NYSDOH) guidelines. We will take your child's temperature and review their symptoms upon arrival. If your child has a fever of 100 degrees or higher OR is showing any of the COVID-19 symptoms below, we will contact you to pick up your child, as is recommended by NYSDOH.
Email address *
What is your child's FULL NAME? *
Has your child shown any of the following COVID-19 symptoms in past 14 days: fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, new loss of smell or taste? *
Has your child had a positive diagnostic COVID-19 test in past 14 days? *
Has your child had close contact (within 6 feet for 10 or more minutes) with a confirmed or suspected COVID-19 case(s) in past 14 days? *
Has your child traveled to a high infection area for COVID-19 anywhere in the US (i.e., state with widespread community transmission per the New York State Travel Advisory) or internationally within the last 14 days that would require quarantine and has not met criteria for release (i.e., quarantined at least 3 days and tested negative on the 4th day for early release)? *
Are any of the ABOVE reported symptoms or situations NEW as of this morning (i.e., we do not already have a doctor's note, negative test result, or other documentation for the symptom/situation)? *
If you have obtained a note from your child's medical provider related to ANY SYMPTOMS noted on this form, BUT the provider refused to describe any detail of the reason for treatment, you may provide the detail here. **For example, if your child failed a previous health screen with us for congestion and runny nose we might have asked you to get a note from the medical provider. If the note only says the child can return to school, you can tell us the child has a history of allergies here to support the provider note. *
I endorse that all of my responses are true at the time of completing this form. I understand that if I answered YES to my child showing ANY COVID-19 symptoms, OR if I answered YES to my child having a positive COVID-19 test in the past 14 days, OR if I answered YES to my child having close contact with a confirmed or suspected case of COVID-19, that my child will not be able to enter the ICD building to receive services. By typing my full legal name below, I assert that I am the legal guardian for the child above and confirm their health status to the best of my knowledge by electronic signature. *
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