Fillable COVID-19 Student Daily Health Check Form

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COVID-19 Student Daily Health Check Form

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The COVID-19 Student Daily Health Check Form form is 1 page long and contains:

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  • 8 check-boxes
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COVID-19 Student Daily Health Check Form
The Washington Departments of Health and Labor & Industries requires school districts to screen all students
to determine if the student has COVID-19 or has been in close contact with an individual exposed to COVID-19.
Student Name
Date
School
Grade
In the past 24 hours has the student experienced any of the following symptoms:
• Fever of 100.4 or above
• Cough
• Shortness of Breath or Difficulty Breathing
• Chills
• Loss of Taste or Smell
• Fatigue
• Muscle Pain or Body Aches
• Headache
• Sore Throat
• Congestion of Runny Nose
• Nausea of Vomiting
• Diarrhea
• Other signs of new illness that are unrelated to a
preexisting condition (such as seasonal allergies)
o
YES
o
NO
Has the student 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.
o
YES
o
NO
Has the student had a positive COVID-19 test for active virus in the past 10 days?
o
YES
o
NO
Within the past 14 days, has a public health or medical professional told the student to self-monitor, self-isolate, or
self-quarantine because of concerns about COVID-19?
o
YES
o
NO
If the answer to any of the questions above is YES, the student must stay home and contact their school.
Name of Person completing this form
Daytime Phone Number
Signature
Date
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COVID-19 Student Daily Health Check Form

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Completed 18 March 2021

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