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COVID-19 2021-2022 Screening for Students
Parents/Guardians: Please complete this short check for the 2021-2022 school year.   In the event that your child's health status changes, you are required to notify his/her respective school immediately and keep your child home until you receive further instructions.  Your submission of this form signifies that you accept and understand the responsibilities contained within the form.

One form for each child must be submitted prior to the first day of school, September 2, 2021.

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Parent/Guardian Name/Nombre: *
Student Last Name *
Student First Name *
Student Grade *
Section 1: Symptoms. Any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms.
Column A:  If TWO OR MORE of the fields in Column A are checked off, please keep your child home and notify the school for further instructions. *
Required
Column B:  If AT LEAST ONE field in column B is checked off, please keep your child home and notify the school for further instructions. *
Required
Section 2: Close Contact/Potential Exposure.  If ANY of the fields in Section 2 are checked off, your child should remain home for 14 days from the last date of exposure (if child is a close contact of a confirmed COVID-19 case) or date of return to New Jersey. Contact your child’s provider or your local health department for further guidance.  Please verify if: *
Required
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