Intent to Return Form (Spring 2021)

UCCA Daily COVID Symptom Check

To ensure the health and safety of our families and staff, please fill out and submit the following Health Assessment Form every morning by 7:45 am. Students and staff will not be allowed on campus without a completed form. When filling out this form each school day morning, you are required to take your child's temperature and record it below. Please submit the form before leaving for UCCA, EACH DAY that they attend UCCA. If you answer YES to any of the following questions, DO NOT bring your child(ren) to UCCA. Teachers will not be responsible for taking this survey for your child(ren).

	Yes	No
Has anyone in your household traveled in the last three days?
Has your child been diagnosed with COVID-19 with the past ten days?
Has anyone who has been in close proximity to your child, including household members, been diagnosed with COVID-19 within the past ten days?

What is your child's temperature this morning? blanks*
Is your child having any of the following symptoms now (or in the past day)? Please check the box next to any symptoms that he/she is having, or check None of the above. *

Fever (Temperature >=100.0F) Chills or shivering Cough Sore throat Trouble breathing None of the above
Is your child having any of the following symptoms now (or in the past day)? Please check the box next to any symptoms that he/she is having, or check None of the above. *

Unusually tired Loss of taste or smell muscle aches None of the above
Is your child having any of the following symptoms now (or in the past day)? Please check the box next to any symptoms that he/she is having, or check None of the above. *

Headache Running nose Diarrhea Nausea/vomiting None of the above
Have you given your child any fever reducing medication, such as Tylenol (Acetaminophen) or ibuprofen, within the last 24 hours? *

Yes No If Yes, Please explain
Please explain:
Signature *

Clear
If you answered YES to any of the questions, please call the school office right away at (510) 489-0394
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UCCA Daily COVID Symptom Check