Covid19 Student Daily Wellness

Covid19 Student Daily Wellness

• Screening questions must be completed daily before entering the school. • The form may be completed at home.
Student Name *

Last Name First Name
Student Grade *
If the answer to any of the below questions is “Yes” you may not report to school today. You must call the school office (305) 238-7562 for further instructions before bringing your child to school.
Within the last three (3) days, have you experienced any
of the following symptoms?
1. Fever or Chills? *

Yes No
2. New uncontrolled cough? *

Yes No
3. Shortness of breath or difficulty breathing? *

Yes No
4. Fatigue, muscle or body aches? *

Yes No
5. New onset of severe headaches? *

Yes No
6. New loss of taste or smell? *

Yes No
7. Congestion or runny nose? *

Yes No
8. Diarrhea, vomiting or abdominal pain? *

Yes No
9. Have you had a fever of 100.4 degrees F or greater (when taken by mouth) in the last three (3) days? *

Yes No
10. Have you had close contact (within six (6) feet of an infected person for at least 15 minutes) with a person who has tested positive for COVID-19? *

Yes No
11. Have you traveled outside of south Florida in the past week? *

Yes No
Date

Month Day Year
Date
Should be Empty: