COVID-19 PATIENT SCREENING QUESTIONNAIRE

MONARCH SCHOOL COVID-19 DAILY HEALTH SCREENING QUESTIONNAIRE

Parents/Caregivers: Please complete and submit this questionnaire by 7:30am each morning, before your child leaves for Monarch School.
Date: *

Month Day Year
Date
Student's Name: *

First Name Last Name
Parent's/Caregiver's Name: *

First Name Last Name
Monarch Program *

Please answer the following questions on behalf of your child (and other members of your household): *

	Yes/No
Is your child's (or anyone else in your household's) temperature, when taken this morning, at or above 100 degrees F?
Has your child (or anyone else in your household) had any of the following unexplained respiratory symptoms in the last 24 hours: sore throat, dry cough, shortness of breath?
Has your child (or anyone else in your household) experienced an unexplained loss of smell or taste in the last 24 hours?
Has your child (or anyone else in your household) experienced any unexplained nasal congestion in the last 24 hours?
Has your child (or anyone else in your household) had any unexplained GI symptoms in the last 24 hours: abdominal pain, diarrhea, nausea, vomiting, loss of appetite?
Has your child (or anyone else in your household) had new or unexplained chills, muscle or body aches, headaches, or fatigue (inability to stay awake) in the last 24 hours?
Has your child (or anyone else in your household) had any unexplained changes in mental status/behavior in the last 24 hours?
If your child (or anyone else in your household) is experiencing any of the above symptoms, are they caused by a preexisting health condition and/or medication? If so, please answer below. (Mark "NO," if not applicable)
Has your child traveled to a state with a high level of COVID-19 in the past 14 days?
Has your child (or anyone else in your household) been in close contact (within 6 feet of an infected person for at least 15 minutes) with someone who has tested positive for COVID-19 or is being evaluated for COVID-19 in the past 14 days?
Has your child (or anyone else in your household) been tested for COVID-19 in the past 14 days?
Has your child (or anyone else in your household) tested positive for COVID-19 in the last 14 days?

If your child (or anyone else in your household) is experiencing any of the above symptoms, and they are caused by a preexisting health condition and/or medication, please explain below.
Out of an abundance of caution (because many of our students are unable to wear masks), if your child - or anyone else in your household - has a fever (100 degrees F or higher), is experiencing any of the COVID-related symptoms above that are unexplained by a preexisting condition or medication, has been in close contact with someone who is confirmed or suspected of having COVID, is scheduled for a COVID test, and/or has tested positive for COVID, please do NOT send your child to school. Contact your child’s pediatrician to determine if s/he has an illness that can be transmitted to others. Based on your doctor’s advice, your child may need to be tested for COVID-19 or another communicable disease. If your child is confirmed as having a communicable disease including COVID, please alert Monarch School and adhere to Monarch’s sick policies. Your cooperation will keep all of us safe – thank you!
Should be Empty: