Parent/Guardian Health Screening Commitment Form
To protect our children and staff, I commit to complete a daily health screening of my child using the COVID-19 Health Screening Questions and to not to send my child to school when he/she is sick or feeling unwell with the symptoms consistent with COVID-19. This commitment will apply to all school-age children in my home.
I agree to screen all school-aged children in my home each day prior to sending him/her to school and agree to keep my child at home if he/she has:
• Feeling feverish and/or having chills (if documented temperature/fever of 100.4F or greater)
• A new cough not due to another health condition
• A new sore throat not due to another health condition
• New chills not due to another health condition
• New muscle pain not due to another health condition or that may have been caused by a specific activity such as physical exercise
• New loss of taste or smell
I understand that the COVID-19 Health Screening Questions may change over time as required by the Centers for Prevention and Disease Control (CDC) and that Fairfax County Public Schools (FCPS) will update the health screening questions, as required. FCPS will communicate any necessary changes to me and I agree to continue daily health screenings based on the current requirements.
I agree not to send my child to back to school if he/she has any of these signs of COVID-19 until:
• My child tested negative for COVID-19 and is otherwise well enough to go back to school OR
• A healthcare provider has seen my child and documented a reason for the symptoms other than COVID-19 OR
• All are true: 1) at least 10 days since the start of symptoms AND 2) fever free off anti-fever medicines for 24 hours AND 3) symptoms are getting better.
I agree not to send my child back to school if he/she is diagnosed with COVID-19, until the following are met:
• It has been at least 10 days since my child first had symptoms AND
• My child has had no fever off anti-fever medicines (ex: Tylenol, Ibuprofen) for 24 hours AND
• My child’s symptoms are getting better
I agree to take my child to a physician for evaluation and completion of the Permission to Return to School/Child Care each time my child is sent home ill during the school day.
If someone in my household has been diagnosed with COVID-19, or my child is exposed, I agree to keep my child home for 14 days after their last exposure to the household member.
*Exposure is defined as spending more than 15 minutes within six feet of a person with COVID-19 or having exposure to the person’s respiratory secretions( for example: coughed or sneezed; shared a drinking glass or utensils; kissing) while they were contagious. A person with COVID-19 is considered to be contagious starting 2 days before they became sick, or 2 days before they tested positive if they never had symptoms.
If someone in my household develops fever, new cough, shortness of breath or two of the following: sore throat, chills, muscle pain, headache, new loss of taste or smell, I will get that person evaluated and tested for COVID-19. If that person tests positive, I will keep my child home for 14 days after their last exposure to this household member OR as above if my child tests positive.
Student-Athlete's First & Last Name
Student-Athlete's Date of Birth
Parent/Guardian's First & Last Name
I verify that I have read, reviewed and understand the information contained in the Parent/Guardian Health Screening Commitment Form.
I commit to the above requirements.
Parent/Guardian Electronic Signature (FULL NAME & DATE)
Send me a copy of my responses.
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This form was created inside of Fairfax County Public Schools.