Copy of Copy of Copy of Student/Family COVID-19 Screening 6 Question Title * 1. Please enter your first and last name (person completing this survey). This will serve as your signature that all information is correct. OK Question Title * 2. Please enter the name and grade of each of your children attending WCS OK Question Title * 3. Is anyone living in your home currently experiencing new or worsening symptoms, such as fever, sore throat, cough, loss of taste or smell, shortness of breath, etc.? Yes No OK Question Title * 4. If yes, please explain. OK Question Title * 5. In the past 14 days, has anyone living in your home been in contact with a person who has been diagnosed with COVID-19 or developed symptoms of COVID-19? Yes No OK Question Title * 6. In the past 14 days, has anyone living in your home traveled from high-risk states as outlined in New York State Executive Order 205? For states with high risk of COVID-19, please visit the following link: https://coronavirus.health.ny.gov/covid-19-travel-advisory. Yes No OK Question Title * 7. If yes, please explain. OK Question Title * 8. Date you completed this survey Date Date OK DONE