COVID-19 SCREENING FORM
Please complete daily before your child attends daycare.
* Required
Parent's Name
*
Your answer
Child's Name
*
Your answer
Does the child or any member of your household have any one of the following symptoms: fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease or loss of sense of taste or smell, chills, headaches, unexplained fatigue/malaise/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye (conjunctivitis), runny nose/nasal congestion without other known cause?
*
Yes
No
Has the child traveled to a Travel Hot Spot in the last 14 days?
*
Yes
No
Does the child have a confirmed case of COVID-19 or had close contact with a confirmed or probable case of COVID-19?
*
Yes
No
Has the child had close contact with a person with acute respiratory illness?
*
Yes
No
Has the child been given fever-reducing medications in the last 5 hours?
*
Yes
No
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