COVID-19 Symptoms Checklist

• Conducted on

  Date

• Prepared by

• Location
  Address

Daily Check

• If you answer Yes to any of these questions, stay at home and contact your school.

• For staff or students (grades 6-12): Do you have any of the following symptoms in the past 24 hours that are not caused by another condition?

  Yes

  No

• For families (grades 5 or below): Does your child have any of the following symptoms in the past 24 hours not caused by another condition?

  Yes

  No

• For anyone returning from a break or for new staff/student: Have they had any of the following symptoms in the past 3 days?

  Yes

  No

Symptoms:

• Fever 100.4⁰F / 38°C or higher

  Yes

  No

• Cough

  Yes

  No

• Shortness of Breath or Difficulty Breathing

  Yes

  No

• Chills

  Yes

  No

• Fatigue

  Yes

  No

• Muscle Pain or Body Aches

  Yes

  No

• Headache

  Yes

  No

• New Loss of Taste or Smell

  Yes

  No

• Sore Throat

  Yes

  No

• Congestion or Runny nose

  Yes

  No

• Nausea or Vomiting

  Yes

  No

• Diarrhea

  Yes

  No

• Other signs of new illness that are unrelated to a preexisting condition (such as seasonal allergies)

  Yes

  No

• Have you been in close contact with anyone with confirmed COVID-19? Close contact means being within 6 feet (2 meters) of an infected person for 15 minutes or more.

  Yes

  No

• Have you had a positive COVID-19 test for active virus in the past 10 days?

  Yes

  No

• Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19?

  Yes

  No

• It is important to seek medical attention immediately if any of your symptoms become severe.

• Name and Signature

  Sign