West Rowan High School - Student Screening Form

Student Daily COVID-19 Screening

West Rowan High School
PLEASE NOTE: Two additional questions added to the screening survey.

In order to protect our students and staff, RSS is proactively screening ALL individuals with potential exposure to COVID-19 prior to beginning the school day.
Reminders:
1. Students should not come to school if exhibiting any of the symptoms listed below.
2. Contact your health care provider if your child is exhibiting any of the symptoms listed below.
3. Hand Washing is the most important way to stop the spread of germs.
4. Students should wear a face covering to school each day and follow social distancing guidelines to decrease potential exposure.
Student's Name *
Grade Level *
Morning bus rider? *

yes no
If yes, what is the bus number? *
Relationship to Student *

Parent/Guardian Self
Does student have a fever higher than 100 degrees? *

Yes No
Has the student taken fever reducing medication in the past 24 hours *

Yes No
Does the student have a new cough for an unknown reason? *

Yes No
Shortness of breath/difficulty breathing for an unknown reason? *

Yes No
Experienced chills for an unknown reason? *

Yes No
Does the student have new loss of taste or smell? *

Yes No
Has the student had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19 or has any health department or health care provider been in contact with you and advised you to quarantine? *

Yes No
Since student was last at school, has she/he been diagnosed with COVID-19? *

Yes No
Is student waiting for results of COVID-19 test? *

Yes No
Is anyone in your household experiencing any COVID symptoms? (chills, fever, loss of taste or smell, cough, or shortness of breath) *

Yes No
By submitting, I attest that the information is true to the best of my knowledge.
Should be Empty:

Student Daily COVID-19 Screening

Reminders: