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Littig House Daily Health Screening Form
If you are are screening for your child, please register your child's name and select "Youth." Para español, haga clic en la esquina superior derecha y cambie el idioma. Para evaluar a su hijo, escriba el nombre de su hijo y haga clic en "Juventud".
Your Name or Your Child's Name
*
First Name
Last Name
Please select one:
*
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Do you have additional household members that will be with Littig House today?
Yes
No
Name
First Name
Last Name
Please select one:
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Name
First Name
Last Name
Please select one:
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Do you have additional household members that will be on campus?
Yes
No
Name
First Name
Last Name
Please select one:
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Grade Level (if applicable):
Please Select
Nevatim
Teenoki
K'Ton Ton
Nitzanim
Chaverim
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Do you have additional household members that will be on campus?
Yes
No
Name
First Name
Last Name
Please select one:
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Do you have additional household members that will be on campus?
Yes
No
Name
First Name
Last Name
Please select one:
Please Select
Youth
Staff
Parent/Guardian
Program Consultant
Visitor
Does anyone in the household have any of the following symptoms?:
*
New and persistent cough
Shortness of breath or any difficulty breathing
Fever
Loss of taste or smell
Sore Throat
No Symptoms
Has anyone in the household been in contact with anyone in the last 14 days who is experiencing these symptoms?
*
Yes
No
Not Sure
Have you recently (preceding 14 days) been in close contact with anyone who has lab confirmed positive for COVID-19?
*
Yes
No
Not Sure
Has anyone in your household been tested for COVID-19 in the past 14 days and still awaiting test results?
*
Yes
No
Parent Signature
Submit
Should be Empty: