COVID-19 Student Health Screening Agreement
Instructions for Parents and/or Guardians

For the health and safety of our students, the Shiawassee County Health Department recommends students to be screened for symptoms of COVID-19 before entering the school. Due to the time and interruption to education doing this on-site prior to school entry this would cause, the health department feels that instructing parents to do this prior to sending their kids to school is acceptable. We ask that you complete the steps of the student screening below, prior to sending your child to school or any school activities or sports. We ask that you complete the form below indicating your understanding and agreement to perform symptom screenings on your child.

By completing this form, I am committing to screening my child daily for the 2020-2021 school year, unless otherwise directed. I also understand that it is my responsibility to call Morrice Elementary and/or Morrice Jr./Sr. High School as soon as possible to let them know if my child is not going to school for potential COVID-19 symptoms.



Student Screening

Before leaving for school, please do the following screening. If your child has any of the following symptoms, it indicates a possible illness that may decrease the student’s ability to learn and put them at risk for spreading illness to others.
Student Name *
Name of Building *
Teacher Name *
Date *
MM
/
DD
/
YYYY
Do you have any of the following symptoms that are new/different/worse from baseline of any chronic illness.
Fever of 100.4 degrees of higher *
New or worsening cough *
Shortness of breath or difficulty breathing - new/different/worse from baseline of any chronic illness *
Chills - new/different/worse from baseline of any chronic illness *
Headache (new onset of severe headache, especially with a fever) *
Sore Throat - new/different/worse from baseline of any chronic illness *
Loss of smell or taste - new/different/worse from baseline of any chronic illness *
Muscle pain - new/different/worse from baseline of any chronic illness *
Had close contact with an individual diagnosed with COVID-19? *
If the answer is YES to any of the symptom questions, keep your child(ren) home from school.
If the answer is YES to any symptoms question and YES to any close contact/potential exposure question or live in an area with high levels of COVID-19 in the community (Risk Level 1-3 found at www.mistartmap.info), call the school as soon as possible to let them know the reason your child(ren) won’t be there today. Call your healthcare provider right away. If you don’t have one or cannot be seen, go to https://www.michigan.gov/coronavirustest or call 2-1-1 to find a location to have your child(ren) tested for COVID-19.
If the answer is YES to any of the symptom questions, but NO to any close contact/potential exposure questions, your student may return based on the guidance for their symptoms(see “Managing Communicable Diseases in Schools”): • Fever: at least 24 hours have passed with no fever, without the use of fever-reducing medications • Sore throat: improvement (if strep throat: do not return until at least 2 doses of antibiotics have been taken) • Cough/Shortness of breath: improvement • Diarrhea, vomiting, abdominal pain: no diarrhea or vomiting for 24 hours • Severe headache: improvement
* This screening tool is subject to change based on the latest information on COVID-19. Source: Centers for Disease Control and Prevention; Screening K-12 Students for Symptoms of COVID-19: Limitations and Considerations
By submitting this form, you authorize that the information above is correct.
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