COVID-19 Student Online Health Screening Form

Student's Name

First NameLast Name

School Name

Grade

Student's Temperature

Name of Person Taking Temperature

First NameLast 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?

YesNo

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

Send me a copy of my responses.

Email

example@example.com