Daily Health Screening (Visitor) Daily Health Screening (Visitor)Visitor's Name*Today’s Date* Date Format: MM slash DD slash YYYY Do you have, [or have you had in the past three days (72 hours)], any of the following symptoms:1. Cough?*YesNo2. Shortness of breath or difficulty breathing?*YesNo3. A fever of 100.4 or higher or a sense of having a fever?*YesNo4. A sore throat?*YesNo5. Chills?*YesNo6. New loss of taste or smell?*YesNo7. Muscle or body aches?*YesNo8. Nausea/vomiting/diarrhea?*YesNo9. Congestion/running nose – not related to seasonal allergies?*YesNo10. Unusual fatigue?*YesNo11. Does anyone in your household have any of the above symptoms that are not attributable to another condition?*YesNo12. Have you been in close contact with anyone with suspected or confirmed COVID-19?*YesNo13. Have you had any medication to reduce a fever before coming to school?*YesNoEmail Address* Please check the box beside the statement:* I certify that the information submitted in this form is true. Your temperature will be taken at the school.
