CI Daily Health Check v4

Introduction
1. This questionnaire is about checking students', staff's, and the faculty's health conditions to prevent COVID19 infection. Please respond sincerely to the survey.
2. Please fill out this form each morning for 7 days before school reopens and continue to do so after the school reopens.
3. Please note that this form is NOT anonymous; only CI Health Office staff have access to its content.
4. This form is HIPPA compliant. Please click here for more information: www.hhs.gov
By proceeding, you acknowledge this above information and agree to the above statements.
Which grade or group do you (your child) belong to? I am or my child is a/an...
My Name (if you are a faculty/staff) or my child's name is...
First NameLast NamePreferred Name
My email (if you are a faculty/staff) or my child's email is...
example@example.com
Do you or your child have any of these symptoms?
Rows Yes No
slightly high temperature between 37.5°C~38°C
high temperature above 38°C
cough
sore throat
difficulty breathing
diarrhea
loss of taste
loss of sense of smell
nausea
Since you answered "Yes" to one or more of the questions above, please share as many details as you feel comfortable with. The CI health office will be the ones to review this information.

Please answer the questions below

Rows	Yes	No
Has/Have your child/you recently traveled abroad (within 14 days)?
Have any of your family members traveled abroad recently (within 14 days)?
Do you have any family members who live together on quarantine?

Since you answered "Yes" to one or more of the questions above, please share as many details as you feel comfortable with. The CI health office will be the ones to review this information.
Notice
You answered "Yes" to one or more of the questions above. According to the guidelines of the Ministry of Education, you (your child) should not attend school.
Please follow these measures.
(1) The current health condition needs you(your child) to stay home. Please cooperate by not attending school.
(2) This will be marked as an excused absence. Please practice preventive measures of COVID-19 and rest at home until 24 hours after the symptoms disappear.
(3) If the fever of 38℃ continues, or the symptoms become worse, please call 1339 or contact the local Public Health Center and visit the screening center for medical treatment. *If you need any extra support from the CI health office, please call 032-250-5119 or email songdo-healthoffice@chadwickschool.org
Acknowledgement
Notice
Please be informed that you (your child) can attend school as you (your child) do not have suspicious symptoms.
Should be Empty:

Rows	Yes	No
slightly high temperature between 37.5°C~38°C
high temperature above 38°C
cough
sore throat
difficulty breathing
diarrhea
loss of taste
loss of sense of smell
nausea