Notre Dame des Victoires
COVID-19 Health Screening Form
Family Last Name(s)
Do you or your child or your carpool live with anyone or have you, your child or your carpool had close contact with anyone with a prolonged cough, fever, flu-like symptoms or been diagnosed with COVID-19 within the last 14 days?
Do you, your child, or your carpool live with anyone, have had close contact or do you, your child, or your carpool have a fever, cough and/or shortness or breath? For children and adults, fever is 99.5 degrees or above using a forehead thermometer.
Do you, your child, or your carpool live with anyone, have had close contact or do you, your child, or your carpool have any other signs of communicable illness such as a cold, flu, rash or inflammation?
In the past 24 hours, including today, have you/your child and or members of your household/carpool had one or more of these symptoms, that is new or not explained by another condition? Fever (99.5 or higher) or chills, cough, shortness of breath or difficulty breathing, loss of taste or smell in the last 10 days (Children may say that food “tastes bad” or “tastes funny”), sore throat, headache, diarrhea, nausea or vomiting.