Daily Health Screening Form
Childcare programs must screen all staff and children before they are permitted to enter the child care space. If any of the answers to the questions in this survey below are yes, the child (or staff member) must not be allowed to enter the building. The child must return home with their parent or caregiver.
Email address *
Child's Name (please note individual surveys must be submitted for each child, please do not include siblings on one survey there is an option at the end to submit another response for additional children) *
Your Name *
Phone number where you can be reached while your child is at our program. *
Today's Date *
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In the past 14 days, have you or your child had close contact with a person known to be infected with the novel coronavirus (COVID-19)? *
Today or in the past 24 hours, have you or any household members had any of the following symptoms? Check all that apply. *
Required
I understand that staff must actively visually monitor children throughout the day for symptoms of any kind, including fever, cough, shortness of breath, diarrhea, nausea, and vomiting, abdominal pain, and unexplained rash. Children who appear ill or are exhibiting signs of illness must be separated from the larger group and isolated until able to leave the facility. The child will be required to be discharged from care within one hour of onset of symptoms. *
Required
Attestation Statement *
Required
Please Enter your Full Name and relationship to the child. *
A copy of your responses will be emailed to the address you provided.
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