Screen and Stay Program
You are receiving this form because the person listed above has been identified as a close contact of a COVID-19 case that occurred during the school day, they have not had any other contact with a known COVID-19 case outside of school, they are unvaccinated or only partially vaccinated, and they are being given the option to continue with in-person learning or work instead of observing normal school quarantine procedures at home. If the person has had other contact with a case outside of school or is fully vaccinated, please contact the school for further instructions.

By initialing/signing this form and providing it to the school, you are indicating that you wish to have the person listed above continue participating with in-person learning or work despite being identified as a close contact of a COVID-19 case and that you agree with the following statements (please initial each statement):

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LAST NAME of Student/Staff Member (Identified as Direct Contact)
FIRST NAME of Student/Staff Member (Identified as Direct Contact)
CONTACT DATE of Student/Staff Member (Identified as Direct Contact)
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SCHOOL of Student/Staff Member (Identified as Direct Contact)
I have read the Screen and Stay guidance document and I understand the requirements for the person listed above to continue with in-person learning or work instead of quarantining at home. *
Required
I understand that Screen and Stay applies only to in-person learning or work and that the person listed above must continue to quarantine away from public/team athletic/social activities and follow normal quarantine procedures for other activities (e.g., team sports, extracurricular activities, gatherings with individuals outside of their household, etc.). *
Required
I (or another adult) will perform a daily symptom assessment of the person listed above each morning at home prior to the person boarding a school bus or otherwise reporting to school for a full 14 calendar days from the Contact Date listed above.   *
Required
The person listed above will quarantine at home and not report to the school, and I will contact the school if they experience any of the COVID-19 symptoms listed at any time during the 14-day monitoring period. Fever (100.4 or higher) or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea   *
Required
Staff/Parent/Guardian Contact Name *
Staff/Parent/Guardian Contact Phone Number *
Today's Date *
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Please sign below affirming the information entered above is, to your knowledge, accurate, and contesting that this screening will be completed daily for the time no shorter than 14 days from the date of contact. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. *
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