Day School COVID-19 Questionnaire

1

Please enter today's date:

Date

2

Parent/Guardian first and last name:Please enter the name of the parent, guardian, or individual filling out this form.

First Name

Last Name

3

Student's first and last name:

First Name

Last Name

4

Phone Number:Best contact phone number should there be any questions or concerns

Area Code

Phone Number

5

Email:

example@example.com

8

Have you or anyone in your household recently been in contact with anyone who has exhibited any of the previous mentioned symptoms?

YESNO

9

Have you or anyone in your household recently (preceding 14 days) been in close contact with anyone who has been lab-confirmed positive for COVID-19?

YESNO

10

Have you or anyone in your household recently traveled outside the United States in the past 14 days?

YESNO

11

In the past 14 days, have you or the student attended a large gathering of more than 10 people where you were in close proximity to other people who were not wearing masks?

YESNO

12

In the last 14 days, have you or anyone in your household been tested for COVID-19?

YESNO

13

If anything changes regarding any of your responses, you agree to notify your student's teacher.

I AgreeI Do Not Agree

14

I have read and understood these questions and agree to the completeness and accuracy of the information I have provided.* This field is required.

I AgreeI Do Not Agree