Daily COVID-19 Acknowledgement Form COVID-19 Daily Acknowledgment Form 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 * Today or in the past 24 hours, have the child or any household members had any of the following symptoms? Fever (temperature of 100.0 F or above), felt feverish, or had chills? * yes no Cough? * yes no Sore throat? * yes no Shortness of breath or difficulty breathing? * yes no Gastrointestinal symptoms (diarrhea, nausea, vomiting)? * yes no New loss of smell/taste? * yes no New muscle aches? * yes no Fatigue? (alone should not exclude a child from participation) * yes no Headache? (alone should not exclude a child from participation) * yes no Runny nose or congestion? (alone should not exclude a child from participation) * yes no Any other signs of illness? * yes no Has the child or anyone in the household had close contact with someone in the previous 14 days with a confirmed or presumptive diagnosis of COVID-19 or someone who is ill with a respiratory illness? * yes no *Close contact is defined as being within 6 feet of an individual for more than 10 minutes, starting 48 hours before symptoms began until their isolation period ends. Is the child or anyone in the household waiting for the results of a COVID-19 test? * yes no Has the child or anyone in the household traveled out of state in the past 14 days? * yes – indicate state(s)yes – indicate state(s) no Has the child or anyone in the household attended a gathering at a private residence of more than 10 people indoors or more than 25 people outdoors? * yes no Children exhibiting any symptoms of COVID-19 will not be permitted to enter the school and must not return until they have met the criteria below: If the child has been exposed to an individual who is COVID-19 positive or presumed to be COVID-19 positive, then they may not return to school for 14 days. If the child has symptoms but has not knowingly been exposed to an individual who is COVID-19 positive or presumed to be COVID-19 positive, they may not return to school until the symptoms abate. Written authorization to return to school from a health care provider is required prior to child’s return to school. Signature * Clear I hereby certify that the responses provided above are true and accurate to the best of my knowledge. Submit Δ
