Return To School Questionnaire
Child 1 Name
*
First Name
Last Name
Child 2 Name
First Name
Last Name
Guardian 1 Name
*
First Name
Last Name
Guardian 1's Profession:
*
Doctor / Nurse
First Respondser
Police Officer / Fire Fighter
National Guard
Teacher
Grocery Store Sales Associate
Delivery Worker
Public Transportation
Essential worker
Office Worker
Other
Guardian 2 Name:
First Name
Last Name
Guardian 2's Profession:
Doctor / Nurse
First Respondser
Police Officer / Fire Fighter
National Guard
Teacher
Grocery Store Sales Associate
Delivery Worker
Public Transportation
Office Worker
Other
Has your child or family traveled outside of Minnesota in the past 14 days?
*
Yes
No
Has your child or your family visited people outside of your household in the past 14 days?
*
Yes
No
Has your child or anyone in your household tested positive for COVID-19 in the past 14 days?
*
Yes
No
Has your child or anyone in your household had close contact with someone tested positive for COVID-19 in the past 14 days?
*
Yes
No
If any of the answers are "yes" above, please add comment:
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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