Student COVID Screen Survey

Student COVID Screen Survey

Student COVID Screening
Complete these questions IN THE MORNING BEFORE sending your child to school.

Name of Student
Date/Time
School Building




Has the student had any of the following COVID-19 symptoms in the past 14 days? Fever (100.0 degrees), sore throat, chills, cough, nausea, diarrhea, muscle pain, shortness of breath or difficulty breathing, new loss of taste or smell, headache, vomiting
UPDATED LIST: Has the student travelled to any of the states prohibited by the Governor’s Executive Order : Alabama, Alaska, Arkansas, Delaware, Florida, Georgia, Guam, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia and Wisconsin
Has the student had a positive diagnostic COVID-19 test in the past 14 days?
In the past 14 days, has the student been in close contact with someone that has tested positive for, or who is suspected of having COVID-19?
If you have answered "No" to ALL of the questions, please send your student to school. If you answered "Yes" to any of the questions, please contact us via email or phone.
Your Name:
Your Email:

To validate your submission, please answer the following math problem:

captcha math problem
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