Central Noble School Absence Screener

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You have been asked to complete this form because your child has been called in absent from school. This form will help your school nurse determine when your child can return to school. PLEASE DO NOT SEND YOUR CHILD TO SCHOOL UNTIL YOU HAVE BEEN CONTACTED BY YOUR CHILD'S SCHOOL NURSE!

Today's date *

YYYY

Student's Name *

Parent Phone Number *

Alternate Phone Number *

Student's School *

Central Noble Primary

Central Noble Elementary

Central Noble Jr/Sr High School

Student's Grade *

Kindergarten

Symptoms that your child is experiencing (please check all that apply) *

fever of 100.0 or higher

Sore throat

new uncontrolled cough that causes difficulty breathing

diarrhea

vomiting

abdominal pain

new onset of a severe headache

new loss of taste or smell

No symptoms

Required

Onset of Symptoms *

YYYY

Last day that your child attended school *

YYYY

Has your student been in close contact with an individual who had a positive COVID-19 test in the last 14 days? *

Yes

Unknown

Plan of Care *

have seen a Healthcare Provider

have an appointment scheduled to see a Healthcare Provider

do not plan on seeing a Healthcare Provider at this time

COVID-19 Testing Results *

not tested

pending

Positive COVID-19 test

Negative COVID-19 test

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