This form will be used to notify the School Nurse when a student or someone they've come into close contact (within 6 feet for ≥ 15 minutes) is experiencing any COVID-19 related symptoms that cannot be attributed to an underlying condition and/or does not meet a student's health baseline. Student privacy will be maintained at all times.

Are you experiencing any of these symptoms?*

Answer Required

Yes

Fever above or equal to 100.4 degrees and/or chills

Yes

Shortness of breath/difficulty breathing

Yes

Cough

Yes

Fatigue

Yes

Muscle aches

Yes

Nausea, vomiting, and/or diarrhea

Yes

New loss of taste and/or smell

Yes

Congestion, sore throat, and/or runny nose

Yes

Headache

Yes

In the past 14 days, have you been exposed to someone with known or suspected COVID-19?*

Answer Required

Yes

Student/Employee/Visitor Name*

Answer Required

Name of responsible party completing this survey*

Answer Required

Contact Phone Number*

Number Required

If you answered YES to any of the above questions, please do not enter campus. You will be contacted by a staff member shortly.

Thank you for completing this Daily COVID-19 Survey.

Please verify you are not a robot:

Please fix errors above

12500 Washington Street, Thornton, CO 80241 Phone: (303) 452-0967 Fax: (303) 452-4519

Calendar Parents Classes Directions