Multi-Language 'STAY SAFE' Health Screening

Victor Central Daily Health Screening Form

Select your language of choice in the bottom right corner of this webpage and follow the directions below to complete the form to the right.  The Form's Progression Buttons are displayed below:

Select this Button to go back to the previous section in the Screening Form

 Select this Button to proceed to the next section in the Screening Form

Submit Button when completed with the Health Screening

One DAILY submission per student/staff member.
Must be submitted 1-Hour prior to the start of your Building Start Time.

  1. Please your email address in the first text box
  2. Use the name listed on SchoolTools / Personnel Office - IMPORTANT... You MUST spell the NAME the SAME WAY each day... including spacing, hyphens, apostrophes, etc...
    • (1A) First Name
    • (1B) Last Name
  3. Person Being Screened
    • Select the first option to complete the screening for a 'Student'
  4. (2A) Select the Building
    • Option 1 - Early Childhood (PK-1)
    • Option 2 - Primary (MA; 2-3)
    • Option 3 - Intermediate (4-6)
    • Option 4 - Junior High (7-8)
    • Option 5 - Senior High (9-12)
  5. (2B) Select the Mode of Transportation and/or if Absent Today
    • Option 1 - School Bus
    • Option 2 - Self / Drop-Off / Walker
      • Type in your child's bus number or the animal name on the bus and select 'next'
    • Option 3 - Absent TODAY
      • (3A) If Absent Today... please complete your reason in the text box and select next.
      • You will then be sent to the confirmation window (checkbox) to submit
  6. (5A) Student Symptoms/Temperature Screening... Symptoms should not be caused by a Preexisting condition or seasonal allergies
    • Left Column - YES
    • Right Column - NO
      • (5B) Fever; Over 100.0 Degrees
      • (5C) Cough
      • (5D) Shortness of Breath
      • (5E) Close Contact with someone with COVID-19
      • (5F) Chills
      • (5G) Nasal Congestion
      • (5H) Sore Throat
      • (5I) Nausea / Vomiting
      • (5J) Diarrhea
      • (5K) New Loss of Taste / Smell
      • (5L) Fatigue
      • (5M) Headache
      • (5N) Muscle or Body Aches
  7. (5O) ACTUAL TEMPERATURE... IMPORTANT - If you have the means to take a temperature now... please enter it below - If not, the Health Office will be completing temperature checks
  8. AGREEMENT / UNDERSTANDING
    • Acknowledgement that students who are ill may not attend school;
    • Acknowledgement that students may not attend school if any member of their household is ill with COVID-19 related symptoms;
    • Agreement that any student or his/her family members experiencing symptoms will contact their health care providers to determine the need for testing for COVID-19 prior to the return to school;
    • Understanding of the information provided on the daily screening procedure;
    • Agreement to all screening requirements and to accurately respond to all screening questions, including the reporting of temperatures daily for all students entering school. 
    • Misrepresentation on any screening questions, including temperatures or masking fevers with medication could result in the student being removed from class and isolated from other students. The parent/guardian/caregiver will be called to pick the student up from school.
    • Agreement to not administer any medication to their child that may mask the symptoms of illness, such as Tylenol or Advil, prior to sending the student to school;
    • Agreement to exclude child(ren) from school immediately upon observing any of the above signs or symptoms of illness in any family member until medically deemed able to return to care; and Consent to provide copies of any of child(ren)’s COVID-19 test results to the school nurse
  9. AFFIDAVIT
    • By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my hand written signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. 
    • I understand that checking this box (OR verbally permitting a Victor Central Staff Member to on my behalf) constitutes a legal signature confirming that I understand, acknowledge, and warrant the truthfulness of the information provided in this document