LARC’s Autism Resource Center COVID-19 Screening
Date
-
Month
-
Day
Year
Date
Parent / Guardian
*
First Name
Last Name
Temperature
Child
First Name
Last Name
Temperature
Child
First Name
Last Name
Temperature
1. Have you experienced any of the following symptoms in the past 48 hours. Check all that apply.
fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss or taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea
2. Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months?
*
Yes
No
3. Have you been in close physical contact in the last 14 days with: • Anyone who is known to have laboratory-confirmed COVID-19?
*
Yes
No
4. Have you been in close physical contact in the last 14 days with: • Anyone who has any symptoms consistent withCOVID-19?
Yes
No
5. Are you currently waiting on the results of a COVID-19 test?
Yes
No
6. Have you traveled in the past 10 days?
Yes
No
If yes, where?
Submit
Should be Empty: