* Required
COVID-19 Information
When to Quarantine & Isolate as Defined by Public Health
Student Last Name:
*
Your answer
Student First Name:
*
Your answer
Date of Absence
*
MM
/
DD
/
YYYY
Absence Type
*
Full Day
Part Day
Reason For Absence
*
Illness
Medical/Dental Appointment
Bereavement
Personal (Unexcused)
Other:
Symptoms: please check all that apply. This will help staff determine if a student may need to quarantine or isolate (please see above graphic for descriptions)
*
This absence is not related to COVID-19 and/or My Student has a History of Symptoms Currently Being Experienced (i.e. Asthma, Allergies)
Cough
Fever over 100.4
Sore Throat
Difficulty Breathing
New Severe & Consistent Headache
Recent Loss of Taste or Smell
Chills
Nausea, Vomiting, or Diarrhea
Muscle Pain
Lives With Someone Who is Ill, or Awaiting COVID-19 Test Results
Other:
Required
Additional Comments (Optional):
Your answer
Multiple Day Absence?
*
Yes
No
Multiple Day Absence Start Date
MM
/
DD
/
YYYY
Multiple Day Absence End Date
MM
/
DD
/
YYYY
Name of Person Reporting Absence
*
Your answer
Relationship to Student
*
Your answer
Email Address of Person Reporting Absence
*
Note: Email address subject to verification with student record.
Your answer
Contact Phone Number
*
Your answer
Electronic Signature and Acknowledgement
*
By entering my name below, I attest that I am the parent/guardian of the above-named student and all the information provided is accurate.
Your answer
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