Daily Health Screening for COVID-19 for Students

Child(ren)'s Name(s) (only include children you are dropping off today) *

When answering the questions below please keep the following in mind:

People should not be at the child care facility if they may have been exposed to COVID-19 or are showing symptoms of fever, chills, shortness of breath, difficulty breathing, new cough, or new loss of taste or smell.

*Fever is determined by a thermometer reading 100.4 or higher or by subjective signs such as flushed cheeks, fatigue, extreme fussiness, chills, shivering, sweating, achiness, headache, not eating or drinking.

**Exposure is sharing a household or having close contact with anyone with COVID 19 or has symptoms of COVID-19.

1. Do you or do any of the children you are dropping off have any of these symptoms? *

Yes

No

Fever* (*Fever is determined by a thermometer reading of 100.4 or higher or by subjective signs such as flushed cheeks, fatigue, extreme fussiness, chills, shivering, sweating, body aches, headache, not eating or drinking.)

Cough

Shortness of Breath / Difficulty Breathing

Chills

New Loss of Taste or Smell

Vomiting or Diarrhea (children only)

2. Have you (or any of the children you are dropping off) had close contact (been within 6ft of someone diagnosed with COVID-19 for a cumulative total of 15 minutes over a 24hr period) in the last 14 days? *

Yes No

3. Since they were last at the child care facility, have you or have any of the children you are dropping off been diagnosed with COVID-19 or been tested for COVID-19 and not yet received your results? *

Yes No

4. Has any health department staff or healthcare provider been in contact with you and advised you or the child(ren) you are dropping off to quarantine? *

Yes No

5. As a family we are doing our part to reduce our risk of exposure to COVID-19 by following the CDC's recommendations for protecting ourselves including frequent hand washing and avoiding close contact and large gatherings. (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html) *

6. I have read and understand WPCC's polices and procedures related to COVID-19. This includes new policies and procedures related to fever and illness. (Last update 6/22/2020; https://drive.google.com/file/d/1E7X1DYRJ6mPfYcwkQ3zFHzyLrEMIWCjn/view?usp=sharing) *

I acknowledge that the information I've given is accurate and complete.

Today's Date *

Date

Parent's Name Completing Form Today *

First Name Last Name

Parent Signature *

Clear

WPCC Daily Health Screening for COVID-19 (Student)