PCCC Daily Health Check

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Please complete this form daily, whether your child is coming to PCCC or is staying home and will be absent due to sickness. We need accurate information for the center to report to the Department of Health if it is needed. With COVID-19, we especially need to know if your child has a fever and if fever-reducing medicine has been given. Thank you for taking the time to complete this form. We are praying for your child's health and your family.

Parent / My name (First & Last) *

Please list your child(ren)'s name below. If you have more than one child, then all names can be listed below UNLESS a child has individual symptoms. Then complete a check-in for that child individually. Thank you! *

Please indicate if in the last 24 hours (or 72 hours if Monday) your child(ren) has any of the following High-Risk symptoms that can NOT be attributed to another condition: *

NONE of the below

Cough (HR)

Shortness of breath or difficulty breathing (HR)

Loss/severe decrease of taste or smell (HR)

Required

Please indicate if in the last 24 hours (or 72 hours if Monday) your child(ren) has any of the following Low-Risk symptoms that can NOT be attributed to another condition: *

NONE of the below

Sore throat (LR)

Unusual fatigue / unexplained muscle or body ache (LR)

Intense headache or migraine (LR)

Cloudy or non-clear runny nose (LR)

Diarrhea (LR) (this requires my child stays home for 24 hours after last diarrhea.)

Vomiting (LR) (this requires my child stays home for 24 hours after last vomit.)

Required

In the last 24 hours has your child had a fever of 100.4*F or greater (HR)? If yes, have you given your child fever-reducing medication in the last 24 hours? *

Yes, over 100.4*F and Yes, medication given (my child is required to stay home)

Yes, over 100.4*F and No medication (my child is required to stay home)

I reviewed my answers and I have... *

answered "NO / NONE" to ALL, or had only one Low-Risk symptom.

marked at least one High-Risk (HR) symptom

marked at least two Low-Risk symptoms

answered "Yes" to fever.

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