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Holland Central Schools: Student COVID Weekly Check-in Form

All students must have a completed form on file for the week. Each child needs to have an individual form completed.

Student Name: *

Parent Name: *

Date *

School Building (single response accepted) If you have another child, another form must be completed) *

Elementary School

Middle School

High School

Do you currently have (or had in the last 10 days) one or more of these *new or worsening* symptoms? Symptoms include: temperature greater than or equal to 100.0 F, feel feverish or have chills, cough, shortness of breath or trouble breathing, fatigue/feeling of tiredness, muscle pain or body aches, headaches, loss of taste or smell, sore throat, congestion/runny nose, nausea, vomiting, diarrhea. *

Yes

In the last 10 days, have you tested positive for COVID-19 or are you still waiting for the test result? *

Yes

In the last 10 days, have you been designated a contact of a person who tested positive for COVID-19 by a local health department? *

Yes

In the last 10 days, have you traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; or traveled to a non-contiguous state? (Contiguous states include: Pennsylvania, New Jersey, Connecticut, Massachusetts, and Vermont)? *

Yes

Acceptance *
Parent/Guardian Attestation

I confirm that my child is not showing symptoms and has replied "NO" to all questions above.

I confirm that my child is showing COVID symptoms, or has replied "YES" to one or more questions above.

Reason (optional)

Your Name

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