APPENDIX 1: AFFIRMATION OF INTENT TO COMPLY WITH SCREEN AND STAY REQUIREMENTS
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Student/Staff Name: *
Contact Date: *
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You are receiving this form because the person listed above has been identified as a close contact of a COVID-19 case that occurred during the school day, they have not had any other contact with a known COVID-19 case outside of school, they are unvaccinated or only partially vaccinated, and they are being given the option to continue with in-person learning or work instead of observing normal school quarantine procedures at home.  If the person has had other contact with a case outside of school or is fully vaccinated, please contact the school for further instructions. By initialing/signing this form and providing it to the school, you are indicating that you wish to have the person listed above continue participating with in-person learning or work despite being identified as a close contact of a COVID-19 case and that you agree with the following statements (please initial each statement):
I have read the Screen and Stay guidance document and I understand the requirements for the person listed above to continue with in-person learning or work instead of quarantining at home. *
 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.).
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.
The person listed above will quarantine at home and not report to the school, and I will contact the school if they experience any of the COVID-19 symptoms listed below at any time during the 14-day monitoring period. *
Staff/Parent/Guardian Signature *
Contact Number *
Date *
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