Health Screening Form Chemung Valley Montessori School COVID Screening QuestionsPlease note you must do one submission for each Chemung Valley Montessori School student in your family.Student Name*Temperature*Please take your child’s temperature and record the results hereHas the child and / or anyone in the household been diagnosed with or is awaiting test results / under investigation for COVID 19 in the past 14 days ?*YESNOHas the child and / or anyone in the household had close contact with a known or suspected case of COVID 19 in the past 14 days ?*YESNOHas the child and / or anyone in the household travelled outside of the country in the last 14 days ?*YESNOHas the child and / or anyone in the household been informed by Public Health or another authority to self-isolate or quarantine in the past 14 days?*YESNOIn the past 14 days, has your child had:A temperature in excess of 100 °F?*YESNOAny medication for fever reduction in the 8 hours prior to school arrival time?*YESNOChills?*YESNOA new or worsening cough?*YESNOSore throat?*YESNOShortness of breath?*YESNODifficulty swallowing?*YESNOLoss of taste or smell?*YESNORunny nose or nasal congestion not attributed to allergies?*YESNOFatigue / lethargy?*YESNOHeadache?*YESNOConjunctivitis ( eye discharge / Pinkeye)?*YESNONausea, vomiting and / or diarrhea?*YESNOParent Signature*Parent Name*Parent Email* Date Date Format: MM slash DD slash YYYY
