K-12 SCHOOL SYMPTOM SCREENING: PARENT/GUARDIAN ATTESTATION
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Grade Level
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KINDERGARTEN
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
Teacher's Last Name
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Your answer
Child's First Name:
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Your answer
Child's Last Name:
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Your answer
Parent/Guardian First Name:
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Your answer
Parent/Guardian Last Name:
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Your answer
Has your child had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?
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Yes > The child should not be at school. The child can return 14 days after the last time he or she had close contact with someone with COVID 19, or as listed below.
No > The child can be at school if the child is not experiencing symptoms
Does your child have any of these symptoms
Fever
Chills
Shortness of breath or difficulty breathing
New loss of taste or smell
Attention
If a child has any of these symptoms, they should stay home, stay away from other people, and you should call the child's health care provider.
Since they were last at school, has your child been diagnosed with COVID-19?
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Yes
No
Attention
If a child is diagnosed with COVID 19 based on a test, their symptoms, or does not get a COVID test but has symptoms, they should not be at school and should stay at home until meet the criteria below.
A child can return to school when a family member can ensure that they can answer YES to ALL three questions
Has it been at least 10 days since the child first had symptoms?
Has it been at least 3 days since the child had a fever (without using fever reducing medicine)?
Has it been at least 3 days since the child's symptoms have improved, including cough and shortness of breath?
Attention
If a child has had a negative COVID-19 test, they can return to school once there is no fever without the use of fever-reducing medicines and they have felt well for 24 hours.
If a child has been diagnosed with COVID-19 but does not have symptoms, they should remain out of school until 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test.
If a child has been determined to have been in close contact with someone diagnosed with COVID-19 they should remain out of school for 14 days since the last known contact, unless they test positive. In which case, criteria above would apply. The must complete the full 14 days of quarantine even if they tested negative.
I attest that the following information is true to the best of my knowledge as of :
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First Name
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Last Name
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