Hard work is child’s play Community Health Screening Form Company Full Name of Person Screened * Classroom * Toddler South Toddler North Blue Room Yellow Room White Room Red Room Junior El West Junior El East Senior El Junior High Staff Community Member Temperature (Farenheit) * Is the person screened experiencing a temperature of or over 100.4°F (without temperature lowering medications); or any of the following symptoms if the symptom is of greater intensity or frequency than what is normally experienced: * Yes No Cough Shortness of breath or difficulty breathing Fever or chills Fatigue Repeated shaking with chills Muscle or body aches Headache Sore throat Loss of taste or smell Diarrhea Congestion or abnormally runny nose Nausea or vomiting In the previous 5 days has anyone in the household been notified of a positive off-campus exposure to someone confirmed to have COVID-19? (If your child has tested positive for Covid-19, has completed their quarantine, and has been cleared to return by Elizabeth Marcilla, our Covid Officer, please select 'No'. * Yes No Has any medication been taken for the purpose of symptom reduction in the last 24 hours? * Yes No Signature *