Student Screen and Stay Survey

Question Title

* 1. School your student attends:

Mary R. Fisher Elementary School

Thompson Middle School

Tourtellotte Memorial High School

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* 2. Student Name:

Student Name

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* 3. Parent/Guardian info.

Parent/Guardian Name

Parent/Guardian Email Address

Parent/Guardian Phone Number

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* 4. Has your student experienced any of the following in the past 24 hours?

Elevated temperature (>100.4 F

Chills

Frequent coughing

Trouble breathing

Unusually tired

Muscle or body aches

Headache

Trouble tasting or smelling

Sore throat

Stuffy or runny nose

Nausea or vomiting

Diarrhea

None of the above

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* 5. Has the person been in close contact with any other individual known to have COVID-19 in the past 24-hours?

Yes

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* 6. Has the person been instructed by local health officials to quarantine or isolate within the past 24-hours?

Yes

If the answers to any of these symptoms or questions is "Yes", remain at home and notify the school.

Student Screen and Stay Survey

Question Title

* 1. School your student attends:

Question Title

* 2. Student Name:

Question Title

* 3. Parent/Guardian info.

Question Title

* 4. Has your student experienced any of the following in the past 24 hours?

Question Title

* 5. Has the person been in close contact with any other﻿ individual known to have COVID-19 in the past 24-hours?

Question Title

* 6. Has the person been instructed by local health officials to quarantine or isolate within the past 24-hours?

* 5. Has the person been in close contact with any other individual known to have COVID-19 in the past 24-hours?