Schnell Student Daily Health Screening
As required by the County Health Officer and According to the Centers for Disease Control and Prevention (CDC)
* Required
Student Name
*
Your answer
Teacher Name
*
Choose
Ms. Starr
Ms. Parra
Ms. Jordan
Ms. Zavala
Ms. Segura
Ms. Stallings
Ms. Malicote
Ms. O'Neal
Ms. Johnson
Ms. Smith
Ms. Shane
Mr. Tillisch
Ms. Bailey
Ms. Peterson
Ms. Wexler
In the last 14 calendar days, has your child traveled out of the U.S.?
Yes, Stop and do not return to school until 14 days from returning home.
No, Go on to next question.
Clear selection
Is your child currently experiencing (or have experienced in the past 14 days) one or more of the symptoms of COVID-19, that are new to you, and that are NOT RELATED to any ongoing condition that you have previously or regularly experienced (i.e., seasonal allergies, migraines, sore throat, chronic mild chest congestion associated with common cold, etc.)? Diarrhea, Fever/Chills, Cough, Shortness of Breath, Difficulty Breathing, Fatigue, Congestion/Runny Nose, Nausea/Vomiting, Muscle or Body Aches, Headache, New loss of Taste/Smell, Sore Throat
Yes, Child must stay home and please contact your health care provider.
No, Go on to next question.
Clear selection
My child has a temperature of 100.4 or higher without temperature lowering medication.
Yes, Child must stay home and please contact your health care provider.
No, Go on to next question.
Clear selection
Is someone in your household, or someone you have come in close contact with (within 6 feet for 15 minutes or more), presenting the symptoms of COVID-19 above?
Yes, Child must stay home please monitor symptoms of child.
No, my child will be at school today.
Clear selection
Submit
Never submit passwords through Google Forms.
This form was created inside of Placerville Union School District.
Report Abuse
Forms