Daily Health Screening Form-Purcellville Montessori Daily Health Screening Form-Purcellville Montessori Student Name*Classroom*Ms. Candice/Primary room#1Ms. Maria/Primary room#3Ms. Kelly/Primary room#6Ms. Rossy/Pre-Primary room#2Ms. Phoebe/Pre-Primary room#4Ms. Diandra/Infant RoomMs. Carrie/Pre-Primary room#7Classroom #2Classroom#3Classroom#4Infant roomClassroom#6Temperature*Fever*YesNoCough*YesNoShortness of Breath / Difficulty Breathing*YesNoSore throat*YesNoRunny Nose / Nasal Congestion*YesNoFeeling unwell / Fatigued*YesNoNausea / Vomiting / Diarrhea*YesNoMuscle Aches*YesNoHeadache*YesNoConjunctivitis*YesNoFamily Health*YesNoIs anyone in your household sick or experiencing any of the above symptoms?Travel*YesNoHave you or anyone in your household travelled internationally, domestically, or to a known hotspot in the last 14 days?Proximity to General Illness*YesNoHave you or your children attending the program had close unprotected* contact (face- to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever?Proximity to Confirmed Case*YesNoHave you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?Parent Signature*Date* Date Format: MM slash DD slash YYYY
