Day School COVID-19 Questionnaire

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Day School COVID-19 Questionnaire

Please fill out the questions in the form. Day School forms are due weekly on Sunday by 5pm for review by school staff. Please do not submit forms before Sunday. Please read through all questions and answer truthfully and honest to the best of your ability. Your honest response helps to keep our students and staff safe.

14Questions

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1
Please enter today's date:
Date
Year
Month
Day
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
6
In the past 72 hours, has the student experienced any of the following?
Fever
Cough
Shortness of breath or difficulty breathing
Headache
Sore throat
Loss of taste or smell
Diarrhea
Fever greater than or equal to 100 degrees
Weakness and fatigue
Tiredness
Loss of appetite
Unexplained changes in behavior
None of the above
7
In the past 72 hours, have you or anyone in your household experienced any of the following?
Fever
Cough
Shortness of breath or difficulty breathing
Headache
Sore throat
Loss of taste or smell
Diarrhea
Fever greater than or equal to 100 degrees
Weakness and Fatigue
Tiredness
None of the above
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
Should be Empty:

Day School COVID-19 Questionnaire

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