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North Fork

Local School District

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Request for
School Info.

Temperature Form

To be completed when student/staff member has symptoms of COVID 19.

Name

Grade

Building

Staff Member or Parent's Email Address

Date Form Submitted

Current Temperature

Time Temperature Taken

Have you had a cough, shortness of breath/difficulty breathing, a fever, chills, muscle pain, sore throat, or loss of taste and/or smell within the last 14 days?

Have you been in contact with anyone that has had a cough, shortness of breath/difficulty breathing, a fever, chills, muscle pain, sore throat, or loss of taste and/or smell within the last 14 days?

Your Name:

Your Email:

To validate your submission, please type the answer to the question.