Covid-19 Screening Tool
Child's name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child exhibit any of the below conditions?
Rows
Yes
No
Fever (temp of 100 degrees or more)
1
2
Cough
3
4
Shortness of breath or difficulty breathing
5
6
Body aches
7
8
Chills
9
10
Runny or stuffy nose
11
12
Sore throat
13
14
Diarrhea
15
16
In the last 14 days:
Rows
Yes
No
Has anyone in your household been diagnosed with Covid-19?
17
18
Have you been told to quarantine yourself by any public health authority? If so, when did/does your 14 day quarantine end?
19
20
Have you been in close contact (less than 6 ft for a prolonged period) with someone who has tested positive for Covid-19?
21
22
Have you traveled anywhere outside of the 50 United States or on a cruise?
23
24
Have you traveled anywhere in the United States by commercial airline?
25
26
DO NOT COMPLETE BELOW THE LINE. OFFICIAL USE ONLY.
Staff to complete
Child's temperature
degree Fahrenheit
Child cleared to enter facility?
Yes
No
Staff signature:
Submit
Should be Empty: