Health Screening Form – Prime Foundation Montessori

MSDE/MDH REQUIRED DAILY HEALTH SCREENING CHILD LOG

Parents/guardians please record your responses to ALL screening questions below AT DROP OFF and BEFORE child’s admission to Facility

Date*
Parent’s/Guardian’s Name:*
Child’s Name*
Symptoms (cough, shortness of breath, fever of 100.4 or higher, nasal congestion, runny nose, fatigue, body ache, sore throat, headache, chills, shivering, muscle pain, loss of taste or smell, and gastrointestinal symptoms (nausea, vomiting, or diarrhea)?*
- Yes
- No
Waiting for a COVID-19 test result, diagnosed with COVID-19, or instructed by any health care provider or the health department to isolate or quarantine?*
- Yes
- No
In the last 14 days, close contact (within 6 feet for at least 15 minutes) with anyone diagnosed with COVID-19 or suspected to have COVID-19 or has symptoms (cough, shortness of breath, fever, nasal congestion, runny nose, fatigue, body ache, sore throat, headache, chills, shivering, muscle pain, loss of taste or smell, and gastrointestinal symptoms (nausea, vomiting, or diarrhea)?*
- Yes
- No
Recorded Temperature taken by parent ON SITE*
Child admitted to Care?
(For Official Use Only)
Parent’s/Guardian’s Signature:
Phone
This field is for validation purposes and should be left unchanged.