JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 DAILY SELF- CHECKLIST
Review this COVID-19 Daily Self-Checklist While at School. Monitoring symptoms is another important preventive strategy for COVID-19. If you reply
YES
to any of the questions below, you must notify your teacher.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name:
*
Your answer
Grade:
*
Your answer
1. Do you have a fever (temperature over 100.3 °F without having taken any fever-reducing medications?
*
YES
NO
2. Do you have a loss of smell?
*
YES
NO
3. Do you have a cough?
*
YES
NO
4. Do you have a muscle ache?
*
YES
NO
5. Do you have a sore throat?
*
YES
NO
6. Do you have a congestion or a runny nose
*
YES
NO
7. Do you have shortness of breath?
*
YES
NO
8. Do you have chills?
*
YES
NO
9. Have you experienced any new gastrointestinal symptoms such as nausea, vomiting, diarrhea, or loss of appetite in the last few days?
*
YES
NO
10. Have you, or anyone you have been in close contact with, been diagnosed with COVID-19 or placed or placed in quarantine for possible exposure to COVID-19 within the last two weeks?
*
YES
NO
11. Have you been asked to self-isolate or quarantine by a medical professional or a local public health official in the last 48 hours?
*
YES
NO
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of To'Hajiilee Community School.
Does this form look suspicious?
Report
Forms
