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COVID-19 Screening Questionnaire

Before they are allowed to enter the building, parents or guardians who drive or walk their children to school may be subject to temperature checks and are required to answer COVID-19 screening questions:

Student First Name

Student's Grade

Student Last Name

Parent / Gardian Full Name

Do you have a fever (temperature over 100.4° F or 38° C) without having taken any fever-reducing medications?

Have you experienced any new gastrointestinal symptoms such as nausea, vomiting, diarrhea, or loss of appetite in the last few days?

Do you have a loss of smell or taste?

Do you have a cough?

Have you, or anyone you have been in close contact with, been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last two weeks?

Do you have muscle aches?

Do you have congestion or a runny nose?

Have you been asked to selfisolate or quarantine by a medical professional or a local public health official in the last two weeks?

Do you have a sore throat?

Do you have shortness of breath?

Do you have chills?

Do you have a headache?

Parent/Guardian Signature

Thanks for submitting!

2022© WHDC CHRISTIAN ACADEMY

(718) 337-5054

whdcchristianacademy@gmail.com

15-21 Central Ave, Far Rockaway, NY 11691, USA

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