Screening Checklist for Students
Name of the Student
*
Student's Building
*
Elementary School
Middle School
High School
Student's Grade
*
Name of the Parent
*
Parent Phone Number
*
-
Area Code
Phone Number
Email address you may be contacted at?
*
example@example.com
1. Has your student tested Positive for Covid?
Yes
No
2. Date of COVID Test
-
Month
-
Day
Year
Date
3. Type of COVID Test
Rapid
Send off
Home Test
4. What location were you tested at?
5. Please upload a photograph or file of your positive result
Browse Files
Cancel
of
6. Date Symptoms Started
-
Month
-
Day
Year
Date
7. Which of the following symptoms does your student have whether testing has occured or not?
*
Fever or Chills
Shortness of Breath or difficulty breathing
Cough
Muscle or Body Aches
Fatigue
Headache
New loss of taste or smell
Sore Throat
Congestion or Runny Nose
Nausea or Vomiting
Diarrhea
Asymptomatic - (No Symptoms)
8. Do you have a Chromebook? (Middle and High School Students Only)
Yes
No
9. Do you have internet access from any source?
Yes
No
Submit
Should be Empty: