Self-Screen

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Rock the Baby

Self-Screen Form

This assessment must be done the morning of, before arriving to school each day.

A child/staff member/person will not be allowed to enter the classroom until this form is received.

Forms must be submitted each day a child/staff/person is due into school, even if not attending.

If not attending, the form must be submitted by 8:30am.

If a person has any symptoms listed below, they might not be able to attend school until permitted by Rock the Baby. Your classroom will contact you when necessary.

Today's Date*

First & Last Name of Child/Staff/Person being assessed*

Reporter's First & Last Name*

If any of the below are checked off as a yes response, the person may not be able to attend school until permitted by RTB. The child/staff/person has or as had in the last 24-48 hours:

Temperature reading of 100 degrees Fahrenheit or aboveCoughSore throatFrequent sneezingRunny noseDifficulty breathingChillsFatigueMuscle aches/painsHeadacheRecent loss of taste or smellRash -unexplained/undiagnosedEye redness, puffiness, bumps (stye), drainageDiarrheaNauseaVomitingFussinessThe person has been given medicine to lower fever or otherIn the past 14 days, has been around/lives with someone that has been diagnosed with OR may have COVID-19In the past 14 days, has traveled outside of the current MA approved states

Describe any other symptoms:

Notes/comments:

Will be ABSENT today -The child/staff/person will not be attending school today due to:

Symptoms checked/described aboveDoes not have symptoms but will not be attending today for other reasons

Will ATTEND school today -The child/staff/person:

(1) Is in good health and able to attend school today(2a) Temperature was taken this morning and read under 100 degrees Fahrenheit(2b) Temperature was NOT taken this morning(3) Has not been given Tylenol or other fever reducing medications(4) Has not been exposed to COVID-19

Confirmation*

I attest that the above information is true and correct

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