UCP Student Health Screening Question Title * 1. Date Date Date Question Title * 2. Child's Name Question Title * 3. Child's Class 5-day PreK 3-day PreK 3-YR-Old Class 2-YR-Old Class Baby/Toddler & Me Question Title * 4. Has your child had a fever of 100 or higher within the past 72 hours? Yes No Question Title * 5. Has your child experienced any of the following symptoms within the past 24 hours that is not typical?Congestion or runny noseCoughSore throatNausea or vomitingDiarrheaMuscle or body achesDifficulty breathing/shortness of breathLoss of taste or smell Yes No Question Title * 6. Has your child tested positive for COVID-19 within the last 14 days? Yes No Question Title * 7. In the past 14 days, have you or your child had known close contact with a person who has tested positive for COVID-19? Yes No Question Title * 8. IF you answered YES to any of the above questions, you/your child may not enter the school building today and must contact your child's teacher with more information. As parent/guardian, please type your name to acknowledge that you have read and understand. Done