STUDENT ABSENCE REPORT FORM
Absence Reporting: Please complete the form below for each child who will be absent with their symptoms/illness/injury.

Please contact the nurse if you have any questions/concerns.

Thank you in advance for your cooperation!
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Email *
First Date of absence *
MM
/
DD
/
YYYY
Student's Name (complete one form for each student who will be absent) *
Parent/Guardian Name *
Contact Phone Number *
Student Grade *
Please explain reason for absence *
Please indicate which symptom your son/daughter is experiencing today which is causing an absence from school: *
Required
Does anyone in your household have any of the above symptoms? *
If you answered yes to the above question, please state the symptoms?
Will you be taking your child to be tested for Covid 19? (If yes, please inform the nurse of the results.)? *
Has anyone in your household tested positive for Covid 19? *
How many days will your son/daughter be absent? *
Do you plan on making an appointment with your primary care physician? *
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