Student Health Absence 2021-22
If your student has new or worsening symptoms and will be absent today, please complete this form before the start of school. If you have questions after submitting this form, contact your division administrative assistant, but the form must be completed first.
First and last name of person completing form
First name of student who will be absent
Last name of student who will be absent
Division of student who will be absent
Reason for student health absence
New symptom development (new onset or worsening of usual symptoms)
Which symptoms is your student experiencing (check all that apply):
New or unexplained persistent cough
Shortness of breath, difficulty breathing
Loss of taste or smell
Runny nose or congestion
Nausea or vomiting
None of the above: My child has a different issue (explain below)
If you selected None of the Above, or answered Chronic Condition, please explain
NOTE: Read the following 4 items and acknowledge symptom protocol below.
1. If student has any symptoms and they resolve in 24 hours, the student can return to school.
2. If they have MINOR symptoms only (sore throat, runny nose/congestion, body aches, headache, fatigue, nausea, diarrhea) AND they resolve within 48 hours, the student can return to school. If minor symptoms persist past 48 hours, then they need negative PCR or molecular test to return.
3. If they have MAJOR symptoms (fever, new/worse cough, difficulty breathing, loss of taste or smell) that last past 24 hours, then they need negative PCR or molecular test to return.
4. If you choose not to test, student needs to home isolate for 10 days from symptom onset and be 24-hours fever free to return.
I acknowledge I have read the symptom protocol above.
Yes, I have read the symptom protocol.
Never submit passwords through Google Forms.
This form was created inside of Alexander Dawson School.