Covid Screening Questions
Please answer the following questions about your family in the past week.
What is your family last name?
Please list the name(s) of your child(ren) enrolled in ICCS.
Does anyone in your immediate family have any of these symptoms that are not caused by another condition? Check any that apply. If none, check NONE of THESE.
Fever or Chills
Shortness of breath or difficulty breathing
Muscle or body aches
Recent loss of taste or smell
Nausea or vomiting
None of these
Within the last 14 days has anyone in your immediate family had contact with anyone that you know had COVID-19 like symptoms? (Contact is being 6 feet or less for more than 15 minutes with a person or having direct contact with fluids from a person with COVID-19.)
Has anyone in your immediate family had a positive COVID-19 test for an active virus in the past 10 days?
Within the past 14 days, has a public health or medical professional asked your family to self-quarantine/isolate because of COVID concerns?
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This form was created inside of Imlay City Christian School.