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CCISD RETURN TO WORK REQUEST
Request must be approved by the Personnel Office prior to returning to work.
You and your supervisor must have written authorization before returning to work. Both parties will receive an email. Updated per local guidance 1/3/22
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Employee Last Name
Employee First Name
Employee Phone contact
Calhoun High School
Travis Middle School
Port O'Connor Elementary
District Wide- Substitutes
Requesting to return on what date:
Return to Work: Negative Results
I received Negative results after a COVID 19 test
I am not household exposed
Employee Test- to- stay: Household Exposure
I am symptom-free
I will self-report and stay at home if symptoms emerge
I agree to Test-To-Stay: No Quarantine with a negative initial CCISD test at onset of exposure and symptom-free
I agree to Test-to-Stay. CCISD test on day 5-7 post- exposure, negative test and symptom free remain at school or work
I will wear a mask or shield due to the household exposure during this time
Employee Request for opt-out of Test-To-Stay: Household exposure I will provide the following information from my healthcare provider: Signed and dated return to K. Taylor or Cynthia Partida
I have a known household close contact that will remain in the home. I, the employee, DO NOT wish to participate in the free TEST-TO-STAY program and agree to provide the below information completed by a healthcare provider
Physician statement (which must document staff Name, Date of Birth. In home exposure date and date allowed to return to work. Must be signed & dated by a Medical Healthcare provider): email documentation to
Employee Signature/Date: (Type name & date below)
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This form was created inside of Calhoun County ISD.