Dailyhealthscreen

Please submit the following survey daily for each student or staff of Queen of Heaven School to monitor the health and well-being of our Students & Staff.

* Indicates required field

Child Last Name/Staff Last Name *

Child First Name/Staff First Name *

Date *

Will you be attending Queen of Heaven school today? *

Yes (Staff) No (Staff) Yes (Child) No (Child)

COVID-19 Contact: Have you knowingly been in close contact in the past 10 Days with anyone who has tested positive for COVID-19? *

Yes No

COVID-19 Testing: Have you or anyone in your immediate family tested positive for COVID-19 in the past 10 days? *

Yes No

COVID-19 Symptoms: Have you experienced any symptoms of COVID-19 in the past 10 days? *

Yes No

If Yes, Please list which symptom(s) below including fevers above 100°F or greater--please list symptom or reason for absence below *

Submit

839 Mill Road, West Seneca NY 14224
Phone: 716.674.5206 | Fax: 716.674.2793

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