Daily Student Symptom Checklist

Daily Student Symptom Checklist

This checklist is intended to be conducted at home by families prior to students attending school.

Yes

No

Prior to coming to school every morning, please answer “Yes” or “No” to the following questions.



Does your student have a new cough that cannot be attributed to another health condition?



Does your student have shortness of breath that cannot be attributed to another health condition?



Does your student have a headache that cannot be attributed to another health condition?



After taking the temperature today, does you student have a temperature greater than 100.0F?



Does your student have any of the following symptoms: chills, repeated shaking with chills, muscle pain, runny nose, sore throat, nausea, vomiting, diarrhea or new loss of taste or smell?



Has your student come into close contact (within 6 feet, for longer than 15 minutes) with someone who has a laboratory-confirmed COVID-19 diagnosis in the past 14 days?



Has a health care provider or public health official asked your student to quarantine 

(i.e., stay home) during this period?


If you have answered “No” to all above questions, your student is safe to enter campus today. If you have answered “Yes” to any of the above questions please stay home and inform your school site. Your school nurse will follow-up regarding next steps.

  • I certify that my student: _______________________________ does not have any symptoms.


___________________________________________


_______________________________ 

Parent SIgnature

Date

_____________________________________________________________________________________________________________________________

Daily Student Symptom Checklist

This checklist is intended to be conducted at home by families prior to students attending school.

Yes

No

Prior to coming to school every morning, please answer “Yes” or “No” to the following questions.



Does your student have a new cough that cannot be attributed to another health condition?



Does your student have shortness of breath that cannot be attributed to another health condition?



Does your student have a headache that cannot be attributed to another health condition?



After taking the temperature today, does you student have a temperature greater than 100.0F?



Does your student have any of the following symptoms: chills, repeated shaking with chills, muscle pain, runny nose, sore throat, nausea, vomiting, diarrhea or new loss of taste or smell?



Has your student come into close contact (within 6 feet, for longer than 15 minutes) with someone who has a laboratory-confirmed COVID-19 diagnosis in the past 14 days?



Has a health care provider or public health official asked your student to quarantine 

(i.e., stay home) during this period?


If you have answered “No” to all above questions, your student is safe to enter campus today. If you have answered “Yes” to any of the above questions please stay home and inform your school site. Your school nurse will follow-up regarding next steps.

  • I certify that my student: _______________________________ does not have any symptoms.


___________________________________________


_______________________________ 

Parent SIgnature

Date


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