COVID Screener

This screener is for use by parents of children served by Acclaim Autism. It's based on this recent CDC guidance. We'll require all staff, parents & children to follow this guidance.

Fully vaccinated is defined by the CDC as:

At least two weeks since a Pfizer and/or Moderna second dose, OR
At least two weeks since a Johnson & Johnson single dose.
*If it's been more than six months, two weeks must have passed since a booster shot.

Additionally, please note if the child or parent are ill, any sessions in the home would need to be canceled as part of our ongoing sick policy, regardless of the below.

Parent:*

First NameLast Name

Child:*

First NameLast Name

Email:*

example@example.com

The Child Is:*

Fully vaccinated against COVID-19Not fully vaccinated

In The Last Five Days, Has The Child Tested Positive for COVID-19:*

YesNoPending

On What Date Did The Child Most Recently Test Positive?

Date

In The Last Five Days, Has a Household Member Tested Positive for COVID-19:*

YesNoPending

On What Date Did The Household Member Most Recently Test Positive?

Date

In The Last Five Days, Has The Child Been In Close Contact With Someone Who Tested Positive for COVID-19:*

YesNoNo, but close contact with someone else, who was in close contact with another person who did test positive for COVID-19

On What Date Was The Child In Close Contact With Someone Who Tested Positive for COVID_19?

Date

In The Last Five Days, Has a Household Member Been In Close Contact With Someone Who Tested Positive for COVID-19:*

YesNoNo, but close contact with someone else, who was in close contact with another person who did test positive for COVID-19

On What Date Was The Household Member In Close Contact With Someone Who Tested Positive for COVID_19?

Date

Does The CHILD Have Any COVID Symptoms? (Fever, Chills, Cough, Shortness of Breath, Fatigue, Muscle Aches, Headache, Loss of Taste or Smell, Sore Throat, Nasal Congestion, Rhinorrhea, Vomiting, Diarrhea, Skin Rashes):

YesNo

Are The Child's Symptoms:

New?Stable?Improving or Gone?

This form is HIPAA-compliant.

Result