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Student Absence Form
Any student that will be absent from school or remote learning will need to complete this form. Please complete the form and then call the school.
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* Indicates required question
Student's name
*
Your answer
Student's teacher
*
Your answer
Date of absence
*
MM
/
DD
/
YYYY
Does your child have any of the following:
*
Fever Chills (fever of 100.4 or higher)
Cough
Sore throat
Diarrhea
abdominal pain
Vomiting
Shortness of breath or difficulty breathing
New onset of a severe headache, especially with fever
Loss of taste or smell
Congestion/Runny nose
Fatigue
None of the above
Other:
Required
Have you or your child had close contact (within 6 feet of an infected person for at least 15 minutes) with a person with confirmed COVID 19?
*
Yes
No
Maybe
Do you have a household member who has tested positive for Covid-19 or who has had symptoms of Covid-19 in the last 14 days?
*
Yes
No
Maybe
Have you traveled to any of the Affected States identified in the State of Connecticut's Travel Advisory (
https://portal.ct.gov/coronavirus/travel
) in the past 14 days?
*
Yes
No
Maybe
Parent/ Guardian filling out this form is a legal signature that affirms that all the information on this form is accurate.
*
Your answer
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