Daily Health Screen

Daily Health Screening Questionnaire

Please answer the following questions about your child each day, at or before drop off

Name of Child

First and last name

1. Was Fever reducing Medication Administered?

Yes

2. Has there been close contact with anyone diagnosed with COVID-19 in the Past 14 Days?

Yes

3. Does the child have any of the following symptoms? Fever *Cough *Shortness of Breath *Trouble Breathing *Headache *Fever *Muscle Pain *Chill *Repeated Shaking with Chills * New Loss of Taste or Smell

Yes

4. Does any household member have any of the following symptoms? *Cough *Shortness of Breath *Trouble Breathing *Headache *Fever *Muscle Pain *Chills *Repeated Shaking with Chills * New Loss of Taste or Smell

Yes

Please specify if you have answered yes to any of the above questions

Name of parent/guardian completing the form