COVID-19 Parental Health Declaration
for Childcare Centers

Child’s Name Date of Birth Parent/Guardian Name Date Childcare Center Name

Health Screening Questions

1. Has your child had any symptoms of COVID-19 such as fever, cough, shortness of breath, or loss of taste/smell in the last 14 days?
2. Has your child been in contact with anyone diagnosed with COVID-19 in the past 14 days?
3. Has your child tested positive for COVID-19 in the last 14 days?
4. Has anyone in your household tested positive for COVID-19 in the last 14 days?
5. Has your child been directed to self-isolate or quarantine by public health authorities in the last 14 days?

Declaration

I, as the parent/guardian, certify that the information provided above is true, and I will inform the center if any of these responses change. I understand the importance of keeping my child at home if they show any symptoms of illness related to COVID-19.