Highland Elementary School Screen and Stay Form-  USE ONLY IF DIRECTED TO BY SCHOOL NURSE
In certain lower-risk situations, students who are not fully vaccinated will be able to remain in school after close contact with COVID-19 case.  If you are a non-vaccinated individual who has been identified as eligible for this option by CPS nursing staff and would like to remain in school you must complete this form after being identified as a close contact and prior to participation in Screen and Stay.  The end date will be provided to you by CPS nursing staff. FAILURE TO COMPLETE THE FORM WILL RESULT IN A CALL HOME TO PICK UP YOUR CHILD.

Parents must complete this form one time at the start of the Screen and Stay period.  Parents should continue to monitor their child for 14 days after the start of the Screen and Stay.  This only allows your child to attend school.  They may NOT participate in other social events unless they test negative 5 days after exposure.  See the close contact letter you received for more information.
Sign in to Google to save your progress. Learn more
Email *
Student LAST name *
Student FIRST name *
Parent name *
Parent phone number *
If my child develops symptoms of COVID-19 during the 14 day screening period I will keep them home and contact the school. *
Please indicate if your child is experiencing any of the symptoms below *
Required
I (or another adult) will perform a daily symptom assessment of the person listed above each morning at home prior to the person boarding a school bus or otherwise reporting to school for a full 14 calendar days from the Contact Date listed above. *
I understand that Screen and Stay applies only to in-person learning or work and that the person listed above must continue to quarantine away from public/team athletic/social activities and follow normal quarantine procedures for other activities (e.g., team sports, extracurricular activities, gatherings with individuals outside of their household, etc.).   Screen and stay school attendance will be revoked if I fail to comply. *
Next Steps
If you indicated that your child is currently experiencing any of the symptoms above you must contact the Highland Nurse's Office at 203-272-0335 during the school day.  

Your child may come to school today if they are not experiencing any of the above symptoms.  PLEASE CLICK SUBMIT BELOW TO CONFIRM THAT WE HAVE A RECEIPT OF YOUR RESPONSES.  
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Cheshire Public Schools. Report Abuse