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Daily Student Absence Form For Illness
Parents please complete DAILY all questions on the form and complete the form individually for each student being reported absent, arriving late, or leaving early for appointments. Thank you.
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* Indicates required question
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student's Grade
*
_4K
_5K
1
2
3
4
5
6
7
8
Elementary Student's Homeroom Teacher
Your answer
Is your student arriving late or leaving early today? Please specify times and reason.
Your answer
Is your student at home due to close contact with an individual testing positive for COVID-19 in the last 10 days? (quarantine)
Yes
No
Clear selection
Has your student been diagnosed with COVID-19 by a health care provider in the last 10 days? (isolation)
Yes
No
Clear selection
Is your child at home waiting for COVID-19 test results?
Yes
No
Clear selection
Please check all the symptoms that your student has experienced in the last 24 hours:
Cough
Shortness of Breath or Difficulty Breathing
New Loss of Sense of Taste or Smell
Fever >100.0
Sore Throat
Unusual Fatigue
Nausea or Vomiting
Runny Nose or Nasal Congestion
Headache
Body Aches or Chills
Diarrhea
Other:
Has your child been vaccinated against COVID19?
Yes
No
Clear selection
Does your child participate in before/after/wrap around care?
Yes
No
Clear selection
Does your student ride the bus?
Yes
No
Clear selection
Guardian Last Name, First Name
*
Your answer
Guardian Cell Phone Number
*
Your answer
Is there anything else you would like to share with us?
Your answer
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