COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE

In response to the recent Coronavirus (COVID-19) outbreak and the raised pandemic alert status, the CDC, the Health and Human Services Commision, and other Local Health Officials have placed strict guidelines on daycare centers to ensure the safety of your child. Taking the appropriate precautions help significantly lessen the spread of the virus. All parents must have a screening form completed before dropping off children.

THIS QUESTIONNAIRE MUST BE COMPLETED OR YOUR CHILD WILL NOT BE ABLE TO ATTEND THE CENTER!

Kingdom Family Children's Learning Center reserves the right to deny entry of your child as deemed necessary. Thank you for your cooperation.

Name (Parent)*

Name (Child)*

Temperature (Child)*

Is your contact information the same? (Address, Phone Number, Email, etc.)*

YesNo

Please enter information that needs to be updated*

Have you, your enrolled child, or anyone in your family (household, including child) tested positive for COVID-19?*

YesNo

Have you, your enrolled child, or anyone in your family (household) been tested for COVID-19 and are currently awaiting the results?*

YesNo

Are you, your enrolled child, or anyone in your family (household) isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?*

YesNo

COVID SYMPTOMS

Fever or chills	Cough	Nausea or vomiting	Sore throat
Shortness of breath or difficulty breathing	Fatigue	Congestion or runny nose	New loss of taste or smell
Muscle or body aches	Headache	Diarrhea

Have you, your enrolled child, or anyone in your family (household) experienced any of the above symptoms in the past 48 hours (READ SYMPTOMS TO INDIVIDUAL):*

YesNo

If YES, add symptoms displayed*

Within the past 14 days, have you, your enrolled child, or anyone in your family (household), been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:

Anyone who is known to have laboratory-confirmed COVID-19?
OR
Anyone who has any symptoms consistent with COVID-19?

Select one for the question above:*

YesNo

Have you, your enrolled child, or anyone in your family (household) traveled OUTSIDE of the United States by air, bus, or train within the last 14 days?*

YesNo

Date*

Date

Signature (Sign with finger)*

Signature of staff member who filled out form