COVID DAILY SURVEY

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Below are the self-screening questions that are required to be answered daily. If the answers are No to all of the following questions, children may enter the school. If you answer YES, please contact the main office and the school nurse.

Student Last Name REQUIRED Please fill out this field. Please enter valid data.
Student First Name REQUIRED Please fill out this field. Please enter valid data.
Teacher's Name REQUIRED Please fill out this field.
Grade REQUIRED Please fill out this field.
1. Has your child been in close or proximate contact in the past 14 days with anyone who has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19?
Q1 REQUIRED YES NO Please fill out this field.
2. Has your child tested positive through a diagnostic test for COVID-19 in the past 14 days?
Q2 REQUIRED YES NO Please fill out this field.
3. Is your child currently experiencing any symptoms of COVID-19, and have had a temperature of greater than 100.0°F in the past 14 days ??
Q3 REQUIRED YES NO Please fill out this field.
4. Is your child's body temperature at or above 100.0 degrees Fahrenheit or has your child (ren) taken any temperature reducing drug. (ie. Tylenol, Advil, Benadryl, Motrin, Aspirin) within the last 24 hours?
Q4 REQUIRED YES NO Please fill out this field.
5) Have you traveled internationally with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days? Please click here for the updated list- https://coronavirus.health.ny.gov/covid-19-travel-advisory
Q5 REQUIRED YES NO Please fill out this field.
6. Since the last time your child reported to school, has he/she had any of the following symptoms:
- Fever or chills- is fever 100.0*F or higher?
- Sore throat, congestion, or runny nose
- New or worsening cough that causes difficulty breathing ( if your child has chronic allergies or an asthmatic cough, is there a change in cough from baseline?)
- Diarrhea, nausea or vomiting
- Onset of severe headache, especially with a fever
- Fatigue, muscle or body aches
- Loss of smell or taste
Q6 REQUIRED YES NO Please fill out this field.
If you answer YES to any of these questions on any given day, your child may not enter the school building. Contact a medical professional for guidance and notify the main office and school nurse.
Name of Parent/Guardian Signing this Form REQUIRED Please fill out this field. Please enter valid data.
Email address of parent submitting Daily Health Assessment Form REQUIRED Please fill out this field. Please enter valid data.

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Our Lady of Victory School

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COVID DAILY SURVEY

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