STUDENT ABSENCE QUESTIONNAIRE

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We understand that your student will not be attending school today. Please fill out this questionnaire to help us better understand your student's absence.

If more than one of your children are absent, please complete a form for each child.

If you have any concerns or questions regarding your child's health, please email our school nurse, Natalie Hall at nhall@c2e.org . She will also follow up, when needed, via email due to your responses in the questionnaire. Thank you.

Parent name (first and last) *

Parent Email Address *

Parent Phone Number *

Student Name (first and last) *

Homeroom Teacher *

Grade Level *

Date(s) of Student's Absence *

Please clarify the reasons for your student's absence. (Check all that apply.) *

My student was sent home sick from school and will be observed at home for symptoms

My student has an appointment or special event and may return to school later today.

My student is out due to illness and will return when they are fever free for a full 24 hours without the use of medications

My student is out due to an accident or injury

My student is out due to travel

Required

To help us better understand your student's illness, please check all of the following symptoms that apply... *

Feeling feverish or having chills or temperature of 100.0 F or above

New or unexplained persistent cough

Shortness of breath, difficulty breathing, or wheezing

Head/body/muscle aches

Sore throat

Nausea/vomiting/diarrhea

n/a or other

Required

Please note any additional information you would like to share in regards to your student's absence: *

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