Saint Mark Daily Health Screening Questionnaire
This form must completed each day for each child.

If you answer YES for any question, your child CANNOT come to school that day.

If you do not complete this for your child (children) they cannot come to school.
Child's Name *
Child's Grade *
Does your child have any of these symptoms: (1) Temperature 100.4 degrees Fahrenheit (2) Sore Throat (3) New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline) (4) Diarrhea, vomiting, or abdominal pain (5) New onset of severe headache, especially with a fever (6) Shortness of breath (7) Fatigue (8) Muscle or body aches (9) New loss of taste or smell (10) Congestion or runny nose (11) Nausea or vomiting (11) Diarrhea *
To the best of your knowledge, in the past 14 days, has your child been in close contact (within 6 feet for at least 10 minutes) with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19? *
Has your child traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days. *
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