KCSD COVID-19 Back to School Questionnaire for Students
To keep our students, families, employees, and communities safe we are following state and local health official's recommendations as we reopen schools for 2020-2021.  This includes completing a COVID-19 Back to School Questionnaire.  Please complete a questionnaire for each child enrolled in the Kenton County School District.  This form must be completed before returning to in-person instruction on September 28, 2020.
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Student First Name
Student Last Name
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone Number
School
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Grade
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Has your student been ill in the last three weeks?
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Check all that apply- In the past three weeks, has your student experinced any of the following symptoms:
Yes
No
Fever
Body Chills or New Rash
Extreme Fatigue
New Uncontrolled Cough
Pain/Difficulty Breathing
Shortness of Breath
Sore Throat
Body/Muscle Aches
Loss of Taste or Smell
GI Symptoms (Vomiting/diarrhea)
Changes in vison/eye discharge
If you responded yes to any symptom, please explain.  
Has your student been previously or is currently diagnosed with COVID-19?
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If yes, please explain.
To the best of your knowledge, has student had any direct contact with someone that has a suspected or lab confirmed case of COVID-19?
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If yes, please explain.
Has your student been self qurantined due to suspected exposure or symptoms of COVID-19?
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If yes, please explain.
Please list and date any places you have travelled outside of the state of KY within the last 14 days.
By electronically signing this form, I acknowledge that:
By typing my name below, I acknowledge I completed the form for my child and read the statement above.  
Date
MM
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DD
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YYYY
Submit
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