Covid Survey

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Child Name *

First

Last

Have you or your child had contact with a person known to be infected, potentially infected, or exposed to someone infected with COVID-19 within the previous 14 days?What is your age? *

Yes No

Have you or your child had someone you’ve been in contact with traveled domestically or internationally in the last 14 days? *

Yes No

Have you or your child been in contact with attended a gathering where proper social distancing protocol was not followed in the past 14 days? *

Yes No

Has you or your child had a fever, cough, shortness of breath, difficulty breathing, chills, muscle pain, sore throat, or new loss of taste or smell that cannot be attributed to another health condition in the past 2-14 days?Choose One *

Yes No

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