COVID-19 Status Report COVID-19 Status Report Child's First Name * Child's Last Name * Adult completing this form * Relationship to child * motherfathergrandmothergrandfatherauntuncleneighbor/friendbabysitter/nannyother Parent Email * Phone number where parent can be reached TODAY * Please check all symptoms and indicate who has exhibited them and when. Fever (temperature of 100.0 F or above), felt feverish, or had chills who? when? temperature?who? when? temperature? Cough who? when?who? when? Sore throat who? when?who? when? Shortness of breath or difficulty breathing who? when?who? when? Gastrointestinal symptoms (diarrhea, nausea, vomiting) who? when?who? when? New loss of smell/taste who? when?who? when? New muscle aches who? when?who? when? Fatigue who? when?who? when? Headache who? when?who? when? Runny nose or congestion who? when?who? when? Other symptoms - please explain what? who? when?what? who? when? Potential exposure: * Close contact with someone in the previous 14 days with a confirmed diagnosis of COVID-19 Close contact with someone in the previous 14 days with a presumptive diagnosis of COVID-19 Waiting for the results of a COVID-19 test Traveled out of state in the past 14 days other (please describe)other (please describe) Use this area to give any important details regarding this situaiton. Thank you for submitting this information. We will report relevant information to our governing agencies and will be in contact regarding next steps. Signature * Clear I hereby certify that the responses provided above are true and accurate to the best of my knowledge. Submit Δ
