𝙋𝙡𝙚𝙖𝙨𝙚 𝙘𝙤𝙢𝙥𝙡𝙚𝙩𝙚 𝙖𝙣𝙙 𝙨𝙪𝙗𝙢𝙞𝙩 𝙙𝙖𝙞𝙡𝙮 before arriving at school
Your responses are safe and confidential.
You must submit 𝑻𝑾𝑰𝑪𝑬, 𝒐𝒏𝒄𝒆 on this page, and 𝒐𝒏𝒄𝒆 on the next.
Bellows Falls Union High School
Bellows Falls Middle School
Saxtons River Elementary School
Central Elementary School
Westminster Center School
Grafton Elementary School
WNESU / Superintendent's Office
Child's First & Last Name
Please, only submit one child per form.
Has your child been in close contact with someone with COVID-19 in the last 14 days?
Does the student feel unwell with any symptoms consistent with COVID-19?
COVID-19 symptoms include the following: ¤ Cough ¤ Fever (100.4 or greater) ¤ Shortness of breath ¤ Chills ¤ Fatigue ¤ Muscle pain or body aches ¤ Headache ¤ Sore throat ¤ Loss of taste or smell ¤ Congestion or runny nose ¤ Nausea, vomiting or diarrhea (diarrhea is defined as frequent loose or watery stools compared to child’s normal pattern)
Has the student had a fever greater than 100.4 in the past 24 hours?
In the past 14 days have you traveled for a non-essential purpose to an area that requires quarantine when returning to VT?
Any leisure travel is considered non-essential. This includes visiting family, shopping for clothes, recreation/sports, hunting. plus others. Essential purposes include essential shopping (such as food and medicine), medical/dental appointments, and work-related travel. Answer "no" to this question if you have answered "yes" previously and that trip has already been cleared by a school nurse/administrator as essential travel which does not require quarantine. If unsure ask your school nurse or look up information or you can check the cross-state travel map here:
N/A - (It has been 14 days since I got my final vaccine dose)
What is your temperature today?
Don't worry if you can't take your temperature at home. You will be re-screened at the school.
Did you answer YES to any of the above questions OR was your temperature greater than 100.4?
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This form was created inside of Windham Northeast Supervisory Union.