CI Daily Health Check

1
Introduction

This questionnaire is required by the Ministry of Education (MOE) and is needed to check the health condition of students, faculty, and staff as a preventative transmission strategy connected to COVID-19.

Please fill out this form each morning for seven days before school reopens and continue to do so after the school reopens.

Please note that this form is NOT anonymous; only CI Health Office staff have access to its content. Its content could be shared with MOE/IOE

This form is HIPPA compliant. Please click here for more information: www.hhs.gov

By proceeding, you acknowledge this above information and agree to the above statements.
2
Which grade or group does the person who will be checked belong to? I am or my child is a/an...* This field is required.
Faculty or a staff member
Pre-K or K student
1st grader
2nd grader
3rd grader
4th grader
5th grader
6th grader
7th grader
8th grader
9th grader
10th grader
11th grader
12th grader
3
Name of the person whose health information is being provided? * This field is required.Please write the name in English (Not in Korean)
First Name
Last Name
Preferred Name
4
Student ID of the person whose information is being provided. (You can find it on the email title with ‘CI health check information’)* This field is required.
5 numbers
5
This person's email address whose information is being given. (Parent email for Earlier grade of Village School students who don't have email address)* This field is required.This is where your results will be sent; your confirmation email must be shown at the door daily.
example@chadwickschool.org
6
Does this person have any of these symptoms?* This field is required.
Yes
No
slightly high temperature between 37.5°C~38°C
high temperature above 38°C
cough
sore throat
difficulty breathing
diarrhea
other respiratory symptoms
loss of taste/sense of smell
nausea/vomiting
slightly high temperature between 37.5°C~38°C
high temperature above 38°C
cough
sore throat
difficulty breathing
diarrhea
other respiratory symptoms
loss of taste/sense of smell
nausea/vomiting
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1 of 9
7
Since you answered "Yes" to one or more of the questions above, please share as many details as you feel comfortable with. The CI health office will be the ones to review this information.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
Please answer the questions below* This field is required.
Yes
No
Has this person recently traveled abroad (within 14 days)?
Have any of your family members traveled abroad recently (within 14 days)?
Does this person have any family members who live together on quarantine?
Has this person recently traveled abroad (within 14 days)?
Have any of your family members traveled abroad recently (within 14 days)?
Does this person have any family members who live together on quarantine?
Yes
No
Yes
No
Yes
No
1 of 3
9
Since you answered "Yes" to one or more of the questions above, please share as many details as you feel comfortable with. The CI health office will be the ones to review this information.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
Notice

You answered "Yes" to one or more of the questions above. According to the guidelines of the Ministry of Education, you or your child should not attend school.

Please follow these measures:

(1) The current health condition needs you or your child to stay home. Please cooperate by not attending school.

(2) This will be marked as an excused absence. Please practice preventive measures of COVID-19 and rest at home until 24 hours after the symptoms disappear.

(3) If the fever of 38℃ continues, or the symptoms become worse, please call 1339 or contact the local Public Health Center and visit the screening center for medical treatment. *If you need any extra support from the CI health office, please call 032-250-5119 or email songdo-healthoffice@chadwickschool.org
11
Acknowledgement
I understand that I (my child) CANNOT attend school.
12
Notice

Please be informed that you (your child) can attend school as you (your child) do not have any presenting COVID-19 symptoms.
Should be Empty: