COVID Screening Child's Name* First Last Parent/Guardian Name* First Last Has your child had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?* No Yes Do you have shortness of breath?* No Yes Have you, or anyone you have been in close contact with, been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last two weeks?* No Yes Does your child have any of these symptoms?Check all that apply Fever Chills Shortness of breath or difficulty breathing Cough New loss of taste or smell Fatigue Muscle or body aches Headache Sore throat Congestion or runny nose Nausea or vomiting Diarrhea Since they were last at school, has your child been diagnosed with COVID-19?* No Yes Signature*
