Timberlane Student Absentee Report for  School Nurses
The Timberlane School Nurses respectfully request that each student member that will be absent , fill out the following questionnaire.  Please make sure to contact your school to notify them of your absence in addition to this form.   Please fill out each day there is an absence.  All answers will kept confidential within the health offices.  By responding to this questionnaire, you are giving permission for a School Nurse to contact you regarding your responses. We thank you for your participation and help in keeping our school community healthy and safe.

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Absentee's First Name *
Absentee's Last Name *
Absentee's School *
Does the absentee have the following symptoms?  Please choose all that apply *
Required
Has absentee had Household contact with anyone with confirmed COVID19?         ***If they have been exposed to a confirmed household case of COVID19, the State of NH requires staying home for 10 calendar days and monitoring for signs and symptoms if NOT fully vaccinated.  Please contact building school nurse to discuss.*** *
Has absentee had household contact with anyone with SUSPECTED COVID19?   *
Has absentee traveled internationally or on a cruise ship in past 10 days?  ** Please contact school nurse for travel quarantine guidance.** *
Has absentee been tested for COVID19? *
If answered  "YES" to above question, please give date of COVID19 testing,  testing results and type of test administered.
If you have any other information that may help nurses with monitoring illness (i.e. exposure, family members in other schools, etc),  please indicate here:
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