Solebury School Health Screening

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Please complete this form daily prior to coming to campus. Thank you!

Last Name of person filling out this form: *

First Name of person filling out this form: *

What is your temperature today? *

Have you or has anyone in your household been in close physical contact with anyone diagnosed with COVID-19 in the past 2 weeks? *

Please note: if your answer is "yes", you should not come to campus and we ask that you contact us at nurses@solebury.org

Yes

Symptom Screen

In the section below, please answer thoughtfully and honestly. If you are experiencing a persistent cough and/or shortness of breath please do not come to campus, and contact your healthcare provider for guidance. If you are experiencing difficulty breathing, please seek immediate help by calling 911. Contact us at nurses@solebury.org with any questions!

Are you or anyone in your household experiencing any of the following symptoms? Please check all that apply. *

Cough

Shortness of breath or difficulty breathing

Fever (measured or subjective)

Chills

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

I am not experiencing any of the above, nor is anyone in my household.

Other:

Required

If you or anyone in your household are experiencing any of the above symptoms, please describe below and notify us at nurses@solebury.org:

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