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 Phone:  (973) 989-4141 
 Fax No: (973) 989-5757
Child Care
   
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Daily Check-in Questionnaire For Students


Student First Name

Student Last Name

Parent/Guardian Name

Student Class

Age Group of your child

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

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

Please mark any and all of the symptoms they are experiencing.

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?

Please mark any and all of the symptoms they are experiencing.

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?

Please mark any and all of the symptoms they are experiencing.

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?

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