Child Name *

First Name

Last Name

Child Symptoms *

Over the past 72 hours has your child had/having any of the following (check all that apply):

None

Fever (Temperature over 100.4°F)

Congestion and/or running nose

Sore throat

Cough

Shortness of breath or difficulty breathing

Chills

Repeated shaking

Muscle pain and/or body aches

Fatigue

Headache

Loss of taste or smell

Diarrhea

Nausea and/or vomiting

Household Symptoms *

Over the past 72 hours has any member of your household had/having any of the following (check all that apply)

None

Fever (Temperature over 100.4°F)

Congestion and/or running nose

Sore throat

Cough

Shortness of breath or difficulty breathing

Chills

Repeated shaking

Muscle pain and/or body aches

Fatigue

Headache

Loss of taste or smell

Diarrhea

Nausea and/or vomiting

Child Covid-19 Test

Has your child tested positive for Covid-19 since last time she/he attended in-person class?

Yes

Child Close Contact

Has your child had close contact (defined as less than 6 feet for at least 15 minutes) with someone with a confirmed or suspected diagnosis of Covid-19?

Yes

Household Covid-19 Test

Has any household member tested positive for Covid-19 since last time your child attended in-person class?

Yes

Household Close Contact

Has any household member had close contact (defined as less than 6 feet for at least 15 minutes) with someone with a confirmed or suspected diagnosis of Covid-19?

Yes

Travel

Has any household member (including your child) traveled out of state anywhere other than VA, MD, or DC since the last time your child attended in-person class?

Yes