Clayville Elementary School Parent/Guardian RETURN TO SCHOOL Attestation
Please read carefully. This is information in regards to screening your child for COVID-19 AFTER illness prior to returning to school. Your signature at the bottom acknowledges you have read and understand this information.
*** A form must be completed for each child.***
This Attestation will be available on the district site for your signature prior to return of your child after illness. Our school nurse and secretary will collaborate to ensure each child has a completed Attestation form daily. The safety of our students, staff, and school community are our top priority.
* Required
First Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Date of absence(s)
*
Your answer
Which of these symptoms were experienced? Please check all that apply.
Cough
Shortness of Breath
Fever or Chills
Muscle or Body Aches
Sore Throat
Headache
Nausea or Vomiting
Runny Nose or Stuffy Nose
Diarrhea
Fatigue
Recent Loss of Taste or Smell
Date symptoms began:
*
MM
/
DD
/
YYYY
Date symptoms ended
*
MM
/
DD
/
YYYY
Was the student/staff member tested for COVID?
*
Yes
No
If no, why not?
Your answer
If yes, when and where was the test completed?
*
Your answer
What was the result of the test?
*
negative
positive
not tested
Other:
Date isolation concluded:
*
MM
/
DD
/
YYYY
Comments
Your answer
Your Signature
I attest that the student is ready to return to school and has:
-Not had a fever (temperature higher than 100.4°) in the last 24 hours
-Not taken any medicine for fever in the last 24 hours
-Improved symptoms and is back to usual h
First & Last Name (this will note as your signature)
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
After-Illness Return Attestation: The questions on this form were generated directly from this form from RIDE and RIDOH. Thank you for your cooperation.
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