Student Daily Health Screening
Student Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Student Grade
*
Grade
Screening Questions:
Within the last three (3) days, have you experienced any of the following symptoms?
Fever or Chills?
*
No
Yes
New uncontrolled cough?
*
No
Yes
Shortness of breath or difficulty breathing?
*
No
Yes
Fatigue, muscle or body aches?
*
No
Yes
New onset of severe headaches?
*
No
Yes
New loss of taste or smell?
*
No
Yes
Congestion or runny nose?
*
No
Yes
Diarrhea, vomiting or abdominal pain?
*
No
Yes
Have you had a fever of 100.4 degrees F or greater (when taken by mouth) in the last three (3) days?
*
No
Yes
Have you had close contact (Someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness on-set or for asymptomatic patients, 2 days prior testing until they time the patient is isolated) with a person who has tested positive for COVID-19?
*
No
Yes
Have you traveled outside of south Florida in the past week?
*
No
Yes
Form completed by:
First Name
Last Name
Submit
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