Del Norte Community School

Student Screening

Page 1

Daily Home Screening for Students Parents: Please complete this short check each morning with your child. If all boxes in section 1 and 2 are unchecked, then your child may bring this form with them and attend school. If you checked any box in section 1 or 2, then please keep your child home and contact your child's school. SECTION 1: Symptoms- If your child has any of the following symptoms, that indicates a possible illness that may decrease the student's ability to learn and also put them at risk for spreading illness to others. Please check your child for these symptoms and mark any that may be present: Temperature 100.4 degrees Fahrenheit or higher when taken by mouth Sore throat New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/ asthmatic cough, a change in their cough from baseline) Diarrhea, vomiting, or abdominal pain New onset of severe headache, especially with a fever SECTION 2: Close Contact/Potential Exposure- If your child has been contact with anyone with COVID-19, since your last screening, please indicate that below. If you check the box, please keep your child home and notify their school office. My child had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19 SECTION 3: Identification & Authorization I understand that if my child is in grades 3-12, a face covering is required, unless I have submitted a note from a healthcare provider exempting my child Student Name Parent / Guardian Name Signature Date CDC G318258-B 07/28/2020

Flyer ID 1040591

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