Weekly Health Questionnaire for in-person programs during COVID

General Contact Information

First Name and Last Name of Student *

Student's Class Name at My French Classes *

For example, CP, Moyenne Section, 5ème....

Teacher's Name

First Name and Last Name of Person Completing the Form *

Email Address *

Email address of person filling out the questionnaire

Phone Number *

Phone number of person filling out the questionnaire

Student Health Questionnaire

Did you take your temperature today? What was your temperature? *

What was your temperature today? *

Have you had a fever (temperature greater than 100.4 F) in the last 48 hours? *

Have you been near someone with a confirmed case of COVID-19 in the past 14 days? *

Do you have a cough, shortness of breath, or a sore throat? *

Have you recently lost your sense of taste or smell? *

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

Do you have any health/wellness concerns for the student today? *

Message

If you would like to send a message, ask a question or make a suggestion, please use the two fields below.

Message