Littig House COVID Daily Health Screening Form

Littig House Daily Health Screening Form

If you are are screening for your child, please register your child's name and select "Youth." Para español, haga clic en la esquina superior derecha y cambie el idioma. Para evaluar a su hijo, escriba el nombre de su hijo y haga clic en "Juventud".
Your Name or Your Child's Name

First NameLast Name
Please select one:
Do you have additional household members that will be with Littig House today?
Name

First NameLast Name
Please select one:
Name

First NameLast Name
Please select one:
Do you have additional household members that will be on campus?
Name

First NameLast Name
Please select one:
Grade Level (if applicable):
Do you have additional household members that will be on campus?
Name

First NameLast Name
Please select one:
Do you have additional household members that will be on campus?
Name

First NameLast Name
Please select one:
Does anyone in the household have any of the following symptoms?:
Has anyone in the household been in contact with anyone in the last 14 days who is experiencing these symptoms?
Have you recently (preceding 14 days) been in close contact with anyone who has lab confirmed positive for COVID-19?
Has anyone in your household been tested for COVID-19 in the past 14 days and still awaiting test results?
Parent Signature
Should be Empty:

Littig House Daily Health Screening Form