D125 Student Self-Certification Form

*Must be Signed by Parent/Guardian prior to Student’s First Day of School Attendance
In response to the COVID-19 pandemic and in order to ensure a safe and healthy environment for our school community, Joint Guidance from the Illinois State Board of Education and the Illinois Department of Public Health requires that every student undergo a daily symptom screening prior to utilizing School District transportation or entering any School District building. Parents/Guardians will be conducting this daily symptom screening prior to their student departing for school and reporting consistent with the parameters outlined below. This form must be signed and returned to the School District prior to the start of the 2020-2021 school year.
Name of Student: _________________________________ Date of Birth: _________________________________
School: __________________________________________ Grade Level: _________________________________
Certification and Verification of Daily Symptom Screening
I verify that prior to utilizing District transportation and/or entering a District building, my student will receive a daily symptom screening at home by an adult caregiver to determine if my student is experiencing any of the following COVID-19 symptoms:
• Temperature of 100.4 (or greater) degrees Fahrenheit/38 degrees Celsius;
• Cough;
• Shortness of breath or difficulty breathing;
• Chills;
• Fatigue;
• Muscle and body aches;
• Headache;
• Sore throat;
• New loss of taste or smell;
• Congestion or runny nose;
• Nausea and/or vomiting;
• Diarrhea; or
• Any other COVID-19 symptoms identified by the CDC or IDPH.
By sending my student on District transportation and/or to school on any given day, I am certifying and verifying that my student has received a daily symptom screening and is not experiencing any COVID-19 symptoms.
If my student is experiencing any of the above symptoms at the time of the daily screening, I will notify the school in writing of my student’s absence by sending an email to the building principal and indicating the above symptoms that my student is experiencing. If District staff contacts me to gather additional information related to the results of my student’s daily screening, I will provide the necessary information as requested.
Certification and Verification of Other COVID-19 Related Exposures
I will notify the school that my student will be absent pending further direction from the District if: (1) my student receives a diagnosis of COVID-19; (2) my student is suspected of having COVID-19; (3) my student comes in close contact (definition below) with an individual who tested positive for COVID-19 or is suspected of having COVID-19; or (4) my student traveled outside of Illinois or internationally. If District staff contacts me to gather additional information related to the reason(s) for my student’s absence, I will provide the necessary information as requested.
By sending my student on District transportation and/or to school on any given day, I am certifying and verifying that my student is not subject to an isolation or quarantine protocol related to COVID-19.
For COVID-19, the CDC defines a “close contact” as “any individual who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection) until the time the patient is isolated.”


Email address *
Name of Student *
Date of Birth *
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School *
Grade level *
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