Student Absence Form

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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.

Student's name *

Student's teacher *

Date of absence *

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

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

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

Maybe

Parent/ Guardian filling out this form is a legal signature that affirms that all the information on this form is accurate. *

Submit

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