2021-22 Daily Health Questionnaire
Centreville Preschool, Inc
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Email *
What is your child's name? (Complete a separate questionnaire for EACH child) *
Which class does your child attend today? *please check only TODAY'S class* *
Has your child had any of the following symptoms in the last 72 hours? *
Required
Has anyone in the household, had any of the following symptoms in the last 72 hours? *
Required
Has there been any use of fever reducing medication within the last 72 hours? *
Within the past 14 days, has anyone in the household been in close physical contact with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? *
Has anyone in the household required a COVID-19 test in the last week? *
Yes
No
Due to Illness or exposure
For Travel
For Work
Is there any clarification regarding any of the above that you wish to note for the Health and Safety Team? *
Submit
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