Student Health Assessment Form

The Health Screening Form has been created to self-assess the well-being of the student prior to attending class for the day. We appreciate your cooperation in gathering this important information.


This form must be filled out in its entirety one hour prior to arriving at the Carrollton Campus.


Based on guidelines from the Governor, CDC and the WHO we have adjusted our routines and protocols to mitigate the risks for students, faculty, and the wider community as we face COVID-19 together. Our approach is a multi-layer preventive defense, but please know that even as we do our best to mitigate risks of transmission on school grounds, there is no such thing as eliminating the risk entirely.
Student Information
(mm/dd/yyyy)
Has the the student or anyone in the household experienced any of the following symptoms in the last 3 days? Select Yes or No.
In the last 14 days, has the student or anyone in the household experienced any of the following? Select Yes or No.
If you checked any of the items listed below to any part of this question, the student should self-quarantine for at least 14 days. We recommend you contact your child's pediatrician for further direction.

If you answered yes:

If you checked any of the above boxes, keep your child home.Please notify Nurse Cooper (Duschene) at gcooper@carrollton.org or Nurse Natalia (Barat) at nuseche@carrollton.org as well as contacting your pediatrician.