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.
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)
Phone number where you can be reached while your child is at our program.
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.
Fever (temperature of 100.0 degrees F or above), felt feverish, or had chills?
In the past 72 hours have you administered fever reducing medication to your child?
Gastrointestinal symptoms (diarrhea, nausea, vomiting)?
New loss of smell/taste?
New muscle aches?
Any other signs of illness?
Neither myself, my child nor any of their household members have experienced any of the symptoms listed above, today or in the past 24 hours.
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.
Yes, I understand and agree to comply with the above statement.
I attest that the information I have submitted is in this survey is honest and accurate.
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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