Sample #2 Daily Health Check

You MUST Submit before leaving this form or ALL entries will be lost.

Child's full name *

Arrival group *

The CDC recommends that parents or guardians take their child's temperature before coming to the child care facility. CDC also recommends that facilities ask parents to confirm that their child does not have fever over 100.4°F, cough, or shortness of breath.

For the health and safety of children, staff, and parents, if your child exhibits any of these symptoms, or any other symptoms of illness, do not bring your child to the center.

Temperature °F *

Check below to confirm your child does not exhibit any sympoms of illness.

My child does not exhibit *

Fever over 100.4°F

Cough

Shortness of breath

Any other symptoms of illness

Electronic signature *

North door 8:00 am	North door 8:15 am	North door 8:30 am
South door 8:00 am	South door 8:15 am	South door 8:30 am