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Student Covid-19 Temperature Check-In
Child's Name
Parent/Guardian Name
Parent/Guardian Tele #
Is your child temperature below 100 degrees (F)?
Yes
No
I am unable to check temperature
In the last 24 hrs did your child experience any of these symptoms (click all that applies)
Abdominal pain
Vomiting
Diarrhea
Rash
Bloodshot eyes
Feeling extra tired
Have you/anyone in your household knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19?
Yes
No
Have you/anyone in your house tested positive through a diagnostic test for COVID-19 in the past 14 days?
Yes
No
Have you/anyone in your household experienced any symptoms of COVID-19, including a temperature of greater than 100.00 degrees Fahrenheit in the past 14 days
Yes
No
Have you/anyone in your house traveled internationally or from a state with a widespread community transmission of COVID-19 per the New York Travel Advisory in the past 14 days?
Yes
No