Student's Name

First Name Last Name

School Name

Grade

Student's Temperature

Name of Person Taking Temperature

First Name Last Name

Please select if the student suffer from any of the symptoms listed below

If the student has any symptoms, KEEP THE STUDENT AT HOME. CALL THE SCHOOL'S ATTENDANCE LINE TO REPORT THE STUDENT'S ABSENCE.

Have you been made aware that you were in close contact with somebody who tested positive for COVID-19?

Yes No

I, undersigned, agree with the following statement:

I certify that the information I have provided here about the student's health status today is accurate.

Date

Signature

Clear

Send me a copy of my responses.

Email

example@example.com

COVID-19 Student Online Health Screening Form