ACDS COVID-19 Self Screening Questionnaire

Student 1, Employee or Visitor Name *

First Name Last Name

Student 1 Grade

Student 2

First Name Last Name

Student 2 Grade

Student 3

First Name Last Name

Student 3 Grade

Symptoms

Has anyone in your household had any of the following symptoms in the last 24 hours that are not caused by another condition? *

Yes

No

Temperature of 100.4 degrees Fahrenheit or higher when taken by mouth

Sore throat

New uncontrolled cough
(for people with chronic allergic/ asthmatic cough, a change in their cough from baseline)

Diarrhea, vomiting, or abdominal pain

New onset of severe headache, especially with a fever

If you answered “yes” to any of these questions, the student or employee must stay home and you should consult a healthcare professional. Return to school will be determined in alignment with the recommendation of a healthcare provider and CDC guidelines. Please contact your Division Head or the Head of School to notify ACDS of the student's absence and discuss the steps in returning to school.

Close Contact / Potential Exposure

In the last 14 days has your ACDS student or have you as an ACDS employee? *

Yes

No

Had close contact (within 6 feet for at least 15 min) with a person with confirmed COVID-19 or who is awaiting COVID-19 test results within the last 14 days?

Traveled outside the DMV within the last 14 days to a location with a 7-day average daily cases of 25 or more per 100,000 people (Risk Level Red)

Up to date COVID travel risk levels for every county can be found here.

If you answered “yes” to any of these questions, the student or employee must stay home and self-quarantine for 14 days. You may return earlier with a negative COVID-19 test, taken in accordance with the recommendations and advice of your healthcare provider.

I certify to the best of my knowledge; this information is accurate.

Date *

Date

Signature *

Clear

Parent Name (if filing out form on behalf of child(ren))

First Name Last Name