China Grove Middle - Daily Student COVID-19 Screening Form

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.

Your child(ren) should not come to school if exhibiting any of the symptoms listed below.
Contact your health care provider if your child is exhibiting any of the symptoms listed below.
Hand Washing is the most important way to stop the spread of germs.
Students should wear a face covering to school each day and follow social distancing guidelines to decrease potential exposure.

Student Name *

Grade Level *

Does your child ride a bus? *

yes no

If yes, what is the bus number? *

Relationship to student: *

Parent/Guardian

Does your child have a fever higher than 100 degrees? *

Yes No

Has your child taken fever reducing medication in the past 24 hours *

Yes No

Does your child 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 your child have new loss of taste or smell? *

Yes No

Has your child 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 your child was last at school, has she/he been diagnosed with COVID-19? *

Yes No

Daily Student COVID-19 Screening Form

Reminders: