Head Start CDC Screening
Today's Date
/
Month
/
Day
Year
Staff's Name
*
First Name
Last Name
Please select a center
*
Please Select
4th Street
67th Street
58th Street
North Bergen
Kearny
Email
*
How are you feeling today?
You have a fever (>100F)? ¿Tiene fiebre (> 100F)?
*
Yes
No
Any symptoms (Temp, Cough, Chest Pain, Diarrhea, loss of taste or smell, Other)? ¿Algún síntoma (temperatura, tos, dolor de pecho, diarrea, pérdida del gusto o del olfato, otro)?
*
Yes
No
Taking Fever Reducing Medications? ¿Toma medicamentos para reducir la fiebre?
*
Yes
No
Family member w/ COVID-19 that live in the same household? ¿Miembro de la familia con / COVID-19? que vive en el miso hogar
*
Yes
No
Submit
Should be Empty: