COVID-19 Self-Certification Form (Students)
In accordance with the Illinois Department of Public Health and Illinois State Board of Education requirements, students must be screened each day for COVID-19 symptoms and other criteria prior to entering a school building or entering a school bus.

Parents must screen their child each day prior to sending their child to school.  

If your child does not meet all the following criteria, you must keep your child at home and notify the school of your child’s absence. Your child will not be permitted to return to school until he/she meets all return-to school criteria or your child’s physician has released your child to return to school, whichever is applicable. If your child is experiencing COVID-19 symptoms, you should consult your health care provider for a diagnosis and treatment.  Your child will not be permitted to return to in-person instruction until you submit a statement from your child’s physician confirming your child is permitted to return to school.  

Note: If your child previously tested positive for COVID-19 in the last three months, and recovered, you do not need to answer the questions marked with a “♦”.  The three month period is calculated from the date of your child’s first onset of symptoms or, if your child was asymptomatic, the date the testing specimen was collected.

During any period of time your child is not attending school, you child will be enrolled in remote instruction.    
By sending your child to school, you are certifying you have screened your child and he/she meets all the following criteria to attend school.

Criteria to Attend School – Checked Daily
♦ My child does not have a temperature of 100.4F or greater.

♦ My child is not taking fever-reducing medicines, such as those that contain aspirin, ibuprofen or acetaminophen, in order to reduce his/her fever.

♦ My child has not had close contact or cared for someone with COVID-19 within the past 14 days.

♦ My child has not returned from travel outside the United States or on a cruise ship or river boat within the past 14 days.

♦ My child has not been directed to self-quarantine by a health care provider.

♦ My child has not been directed to self-quarantine by the County or State Department of Public Health.

♦ No one within my child's household is currently being evaluated for COVID-19 symptoms or waiting on the results of a COVID-19 test.

My child does not have any of the following symptoms:
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Sore Throat
Congestion or runny nose

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Email *
Student's Last Name *
Student's First Name *
Grade Level *
I hereby acknowledge that I have received a copy of this COVID-19 Daily Self Checklist. I understand that I am required to honestly and accurately complete this checklist each day before sending my child to school. You do not have to fill the form out daily, but you do need to review the list and make sure your child has no symptoms any day.  This constitutes parent signature, please sign type your name as the parent or guardian, that you understand by signing this form you will not send your child to school with any symptoms.  Please type your name below to acknowledge this form and that you know by signing this you are certifying your child has NONE of the symptoms on any day they come to school.   *
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