Health Survey - Questionnaire

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* 1. Child/Children's Name

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* 2. Date/Time

Date
Time

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* 3. Has your child/children had a fever of 100.4 or higher in the last 24 hours?

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* 4. Has your child/children or anyone in your household had a respiratory infection, cough, shortness of breath, low-grade fever, experienced GI distress, diarrhea or vomiting?

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* 5. In the previous 14 days, has your child or anyone in hour household had contact with someone with a confirmed diagnosis of COVID19, is under investigation for COVID19; or is ill with a respiratory illness?

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* 6. In the previous 14 days, have you traveled internationally to countries with widespread, sustained community transmission?

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* 7. In the previous 7 days, have you traveled outside the state of Florida?

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* 8. Your name:

Thank you for completing this survey.

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