Covid - 19 Check In COVID-19 Check In Question Title * 1. In the last 14 days, have you received a confirmed diagnosis for coronavirus ( COVID-19) by a coronavirus ( COVID -19) test or from a diagnosis by a health care professional or are you waiting for a pending COVID-19 test result? YES NO Question Title * 2. In the last 14 days, have you had close contact with or cared for someone currently diagnosed with COVID-19 ? YES NO Question Title * 3. In the last 14 days, have any one in your family experienced any cold or flu symptoms ( to include fever,cough, shortness of breath or difficulty breathing, sore throat, pressure in the chest, diarrhea, vomiting, muscle pain, loss of smell or taste)? YES NO Question Title * 4. Does your child have any of the following symptoms running nose, cough, fever, or diarrhea? YES NO Does Not Apply Question Title * 5. I understand that if my child experience any of the following symptoms at the Learning Center today running nose, fever, diarrhea, continuous cough, I must pick up my child within 45 minutes AGREE DO NOT AGREE DOES NOT APPLY Question Title * 6. What is your child’s name? Question Title * 7. What is your first name and last name Question Title * 8. I am a Parent/ Guardian to student Employee Visitor Question Title * 9. ENTER DATE/ TIME TIME Date Time AM/PM - AM PM Done