Pediatric COVID-19 Screening Questionnaire
Please complete this form to help screen for possible COVID-19 symptoms or exposure in your child. This information supports safe participation in group settings.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Has your child experienced any of the following symptoms in the past 48 hours?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
None of the above
Has your child had close contact with a confirmed or suspected COVID-19 case in the past 14 days?
*
Yes
No
Not sure
Has your child traveled outside your local area in the last 14 days?
*
Yes
No
Has your child attended school, daycare, or group activities in the past 14 days?
*
Yes
No
Is your child currently awaiting results from a COVID-19 test?
*
Yes
No
If you have any additional notes or information, please provide them below
Submit Screening
Should be Empty: