COVID Daily Health Screening Form for School

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Do you have additional household members that will be on campus?

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Do you have additional household members that will be on campus?

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Do you have additional household members that will be on campus?

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Do you have additional household members that will be on campus?

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Do you have additional household members that will be on campus?

Name

First NameLast Name

Please select one:

Grade Level (if applicable):

Does anyone in the household have any of the following symptoms?:

Has anyone in the household been in contact with anyone in the last 14 days who is experiencing these symptoms?

Have you recently (preceding 14 days) been in close contact with anyone who has lab confirmed positive for COVID-19?

Has anyone in your household been tested for COVID-19 in the past 14 days and still awaiting test results?

Parent Signature

AYA Daily Health Screening Form