Employee Remain In School (RIS) Attestation Form

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Employees who are unvaccinated with known exposure to someone with diagnosed or presumed COVID-19 and are considered a presumed close contact are encouraged to test at home, prior to arrival at school, on day 2 and day 5, after exposure, and report the results using the form below.

Email *

Employee's Last Name *

Employee's First Name *

School/District Building *

Francis X. Hegarty

Lincoln Orens Middle School

Conference Center

Date COVID-19 Test Was Administered At Home *

YYYY

This test was administered on Day 2 or Day 5 (please select below) after exposure (which would be Day 0). *

Day 2

Day 5

Test Result *

Negative

I attest that I administered an at-home test for the date specified above. I further attest that the test result was negative. *

Yes. I attest that I administered an at-home test on the date specified above. I further attest that the test result was negative.

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