Covid Screening Questions
Please answer the following questions about your family in the past week.
* Required
Email address
*
Your email
What is your family last name?
*
Your answer
Please list the name(s) of your child(ren) enrolled in ICCS.
*
Your answer
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
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Recent loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea
None of these
Required
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.)
*
Yes
No
Has anyone in your immediate family had a positive COVID-19 test for an active virus in the past 10 days?
*
Yes
No
Within the past 14 days, has a public health or medical professional asked your family to self-quarantine/isolate because of COVID concerns?
*
Yes
No
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