COVID-19 Return To School/Work Form
If you (staff, faculty or if you are a parent answering for a student) have been directly exposed to a person who tested positive for COVID-19, you must meet certain criteria to return to school/work.

* PLEASE FILL THIS OUT ON THE 10TH DAY AFTER YOUR POTENTIAL EXPOSURE *
* This form replaces the need for a doctor's note. *

Please answer the following:

Do you (staff, faculty or if you are a parent answering for a student) have, or have had in the last 10 days, one or more of these new or worsening symptoms:

● A temperature greater than or equal to 100 degrees fahrenheit measured today with an oral or rectal thermometer and without the use of fever reducing medication?
● Feel feverish or have chills
● Cough
● Loss of taste or smell
● Fatigue/feeling of tiredness
● Sore throat
● Shortness of breath or difficulty breathing
● Nausea, vomiting or diarrhea
● Muscle pain or body aches
● Headaches
● Nasal congestion/runny nose
● Unexplained rash

Please be advised that if you (staff, faculty or if you are a parent answering for a student) have any of the symptoms above and attribute them to some other diagnosis, this form is NOT acceptable. For example, if you believe your runny nose to be attributed to allergies, you will need this verified by your healthcare provider, NOT the school nurse.

Answer: *
Date of Exposure *
MM
/
DD
/
YYYY
Today's Date *
MM
/
DD
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YYYY
First Name of Student or Staff Member *
Last Name of Student or Staff Member *
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