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As part of the NYS Education Department Guidelines for school reopening, we are required to administer periodic health screenings to all students in an effort to minimize the spread of COVID-19.

Please fill out one form per child.

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* 1. Parent/Guardian's First Name:

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* 2. Parent/Guardian's Last Name:

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* 3. Phone Number:

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* 4. Child's Full Name:

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* 5. Building Child Attends:

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* 6. Child's Grade

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* 7. Is this child experiencing shortness of breath?

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* 8. Has this child had a temperature higher than 100.0 in the past fourteen days?

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* 9. Is this child in close contact with someone currently diagnosed with COVID-19?

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* 10. Has this child been in close contact with someone currently diagnosed with COVID-19 in the past fourteen days?

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* 11. Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days? Note: For a list of states currently under New York’s travel advisory requiring a 14-day quarantine upon return, please visit:
https://coronavirus.health.ny.gov/covid-19-travel-advisory#restricted-states

If you answered "Yes" to any of the questions above, your child and any other school age children in the same home are to stay home from school. It is strongly recommended that you contact a healthcare provider. You will also be contacted by a Center Moriches School District staff member regarding your child's health.

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* 12. By entering my full name below, I acknowledge that my answers to the above questions are true.

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