Daily Check-in Questionnaire For Students

Student First Name

Student Last Name

Parent/Guardian Name

Student Class
—Please choose an option—School AgePreKPreschool 2Preschool 1ToddlersLittle TotsInfants

Age Group of your child
0 – 2.52.5 – 56 – 13

Have you given the above child any medication that could possibly lower their temperature?
YesNo

Has the child been coughing, showing signs of shortness of breath, difficulty breathing, new loss of taste or smell?
YesNo

Please mark any and all of the symptoms they are experiencing.
CoughingShortness of BreathDifficulty BreathingNew loss of tasteNew loss of smellMy child does not show any of the above symptoms.

Has the child shown signs of any the following symptoms: chills, shivers, muscle aches, headache, sore throat, nausea/vomiting, diarrhea, fatigue, congestion, or a runny nose?
YesNo

Please mark any and all of the symptoms they are experiencing.
ChillsShiversMuscle achesHeadacheSore throatNauseaVomitingDiarrheaFatigueCongestionRunny noseMy child does not show any of the above symptoms.

Has anyone in your household shown signs of the following symptoms: Coughing, shortness of breath, difficulty breathing, new loss of taste or smell, chills, shivers, muscle aches, headache, sore throat, nausea, vomiting, diarrhea, fatigue, congestion, or a runny nose?
YesNo

Please mark any and all of the symptoms they are experiencing.
CoughingShortness of BreathDifficulty BreathingNew loss of tasteNew loss of smellChillsShiversMuscle achesHeadacheSore throatNauseaVomitingDiarrheaFatigueCongestionRunny noseNo one in my household has any of the mentioned symptoms.

Has the child been in contact with someone with COVID-19 or has been within 6 feet for more than 10 minutes in the last 14 days?
YesNo

Has the child traveled to an area of high community transmission?
YesNo