Editing previous response:

Please fix the highlighted areas below before submitting.

Daily COVID-19 Questionnaire.Franklin

STAFF:  Please complete this short questionnaire each morning before the start of school (between 5-8 a.m.) to allow time for your school to check questionnaire responses. You must continue to take your temperature each morning.

SECTION 1: Symptoms (Check ONE)*
Answer Required
  • A fever of 100.0 F or above
  • A new cough (For persons with chronic allergic/asthmatic cough, a change in their cough from baseline)
  • A sore throat
  • A new onset of severe headache, especially with fever
  • Diarrhea, vomiting, or abdominal pain
  • Difficulty breathing or shortness of breath
  • Change in or new loss in sense of taste or smell
SECTION 2: Close Contact/Potential Exposure (Check ONE)*
Answer Required
  • Close contact (within 6 feet for a cumulative 15 minutes over a 24-hour period) with a person with a confirmed case of COVID-19 or with a person who is awaiting result of a COVID-19 test due to symptoms; or
  • Been diagnosed with COVID-19 within 10 days; or
  • Been asked to quarantine by a medical professional or local public health official in the last two weeks.
SECTION 3: Travel (Check ONE and contact your school nurse with any questions)*
Answer Required
I verify that all information on this form is correct to the best of my knowledge.*
Answer Required
Confirmation Email