MOUNTAIN VILLAGE SCHOOL
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Weekly Health and Safety Questionnaire
In order to keep everyone safe and healthy at MVS we are asking all families to complete this questionnaire on a weekly basis.
Please refer to the following health and safety guidance:
Vermont Travel Guidelines
Vermont Department of Health Guidelines for Child Care Programs
Indicates required field
Child or Children
In the past week:
Has anyone in your family been out of the state in the past week? If answering yes, please follow quarantine guidance.
Essential Travel (see the VDH website for definition and guidelines)
In the past week have you had visitors from out of state in close contact with you or anyone in your family? The CDC defines close contact as being within 6 feet for at least 15 minutes. If yes, did they abide by the VT quarantine policy?
Yes, we had visitors and they abided by the quarantine policy
Yes, we had visitors but they did not properly quarantine
In the past 7 days have you or anyone in your household: tested positive for COVID-19, (2) been in close contact with someone who has COVID-19, and/or (3) been living with/providing direct care for someone who has COVID-19?
Have you or anyone in your household waiting for COVID-19 results ?
Do you have any siblings or members of your household who are sick at home?
Yes - new or unexplained illness of sibling or household member - awaiting physician evaluation - restricted from attending school
Yes - the child presenting for this questionnaire continues to remain symptom free, it has been greater than 24 hours, and physician evaluated siblings/household member, diagnosis given unrelated to COVID-19.
Has your child had any of the following symptoms in the past week
Shortness of breath or difficulty breathing
Loss of taste (new)
Loss of smell (new)
Fever of 100.4 F or higher
Muscle or body aches
Congestion or runny nose (new)
Nausea or vomiting
None of the above
If your child has any one of the above symptoms, please keep them home for a minimum of 24 hours to monitor. If the symptoms do not persist and there are no additional symptoms, they may return to school. If your child has a fever they must remain out of school for 36 hours with no fever and without the aid of fever reducing medication.
I agree that the information I am providing is true and correct. I understand that my child will not be allowed to come to school if the questionnaire has not been answered each week. I understand that failure to answer honestly could result in the removal of my child from school until the pandemic has been resolved.
Mountain Village School, LLC