CPS COVID-19 Student Certification and Verification Form
In response to the COVID-19 pandemic and in an effort to create a safe and healthy environment for our school community, the Chicago Public Schools (“CPS”) will be following the Illinois Department of Public Health (“IDPH”) and Illinois State Board of Education’s (“ISBE”) guidance regarding who should be present onsite in our schools and requiring each student to undergo a daily health screening prior to entering their school building. In accordance with this guidance, parents/guardians must conduct a daily health screening prior to their child departing for school each day. Parents/guardians must report consistent with the instructions outlined below, unless otherwise notified by CPS. This form must be completed and submitted to your child’s school by September 3, 2021 and will be in effect for the first quarter. Parents will be asked to complete this form again for each of the remaining quarters during SY21-22.
Procedures for Certification and Verification of Daily Symptom Screening and Other Related COVID-19 Exposures
As the parent/guardian, I or an adult caregiver for my child, will conduct a daily symptom screening of my child to determine if my child is currently experiencing any of the following COVID-19 symptoms which cannot be attributed to another health condition: Fever (100.4 degrees or higher) or chills, cough, shortness of breath or difficulty breathing, chills, fatigue, muscle and body aches, headache, sore throat, loss of taste or smell, congestion or runny nose, nausea and/or vomiting, diarrhea.
I acknowledge and agree that my child will not be permitted to enter upon a Chicago Public School and will notify the school that my child will be absent on that day, if:
My child’s daily symptom screening reveals that my child is experiencing any COVID-19 symptoms which cannot be attributed to another health condition. My child tested positive for COVID-19 within the last 10 days. My child is waiting on the results of a COVID-19 test (excluding CPS school-based screen program). My child is not fully vaccinated and within the past 14 days had close contact with someone diagnosed with COVID-19. (Outside of the classroom setting, the CDC defines “close contact” as “someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.”) My child is not fully vaccinated, within the last 10 days my child traveled to a state or territory identified as ORANGE or RED in the City of Chicago Travel Advisory, and my child cannot produce a negative COVID-19 test or qualify for an exception as listed in the Advisory. (Chicago’s Travel Advisory can be found here:
) My child is not fully vaccinated, and my child traveled internationally within the last 10 days (or 7 days with a negative COVID-19 test upon return).
As our students return to in-person learning five days a week, everyone must do their part to keep our community safe. This means that everyone in the CPS family, including students, parents/guardians, teachers and staff must practice the same safety measures that our students are using in-person at school. Therefore, in order to keep our school communities safe, you agree to the following: Adhere to social distancing, wearing cloth face coverings or masks, and practicing good hand hygiene at school or home and in your social pods and community; Adhere to quarantining requirements for the appropriate number of days depending on the travel location; Observe and teach the same healthy hygiene habits we use at school at home: 20-second hand washing, appropriate use of face coverings, catching coughs and sneezes in a tissue or your elbow; Make the decision to stay home if you are sick or awaiting COVID-19 test results; and Be an example for your children and neighbors in modeling safe, responsible behaviors and compassion for others.
By acknowledging below or sending my child to school, I agree and certify the following:
As the parent/guardian, I or another adult caregiver, will conduct a symptom screening of my child each day and follow the appropriate procedures listed above prior to my child entering a Chicago Public School. If my child is experiencing any COVID-19 symptoms or any other COVID-related exposures listed above, I will not send my child to school and will notify the school of their absence. If Chicago Public Schools staff contacts me to gather additional information related to the results of my child’s daily screening, I will cooperate and provide the necessary information as requested. Comply with the collective responsibility procedures outlined above. My student must be symptom free in order to participate in in-person learning or any other CPS sponsored event.
Student Full Name
112, Abrams (Boros)
309, Cole (Francomb)
Parent/Guardian Name (First & Last)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Chicago Public Schools.