Lineham After-Illness Return Attestation
This attestation can be completed by a parent/guardian or a staff member. It does not need to be completed by a healthcare provider.
Name of student/staff:
Date of birth:
MM
/
DD
/
YYYY
Phone number:
School/program name:
Please provide dates of absence *
Please check all symptoms that apply. If your child had any ONE of the following symptoms you must be tested for COVID-19.
Please check all symptoms that apply. If your child had any TWO of the following symptoms you must be tested for COVID-19.
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