COVID Health Declaration | P.S. 214

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Covid-19 Health Declaration

How are you feeling today?

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Last Name

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My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Your Signature

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

THE LORRAINE HANSBERRY ACADEMY P.S. 214

1970 W Farms Rd, Bronx, NY 10460

Monday - Friday

8:00 am - 2:20 pm

Phone: (718) 589-6728

Fax: (718) 589-6728

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