Twain Elementary School Illness and COVID-19 Exposure Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

INSTRUCTIONS:
1. Please call the attendance line at 303-734-5825.
2. Only complete this form if you are reporting an illness or a COVID-19 positive case/exposure.
3. If your student is absent for multiple days, you do not need to complete this form again unless there is new information regarding test results or exposures
4. Please complete a SEPARATE form for EACH student in your household.
5. For more information, please refer to the FAQ's: https://littletonpublicschools.net/covid-faqs-parents.

1. Student First Name *

2. Student Last Name *

3. Student Date of Birth *

YYYY

4. What grade is your student in? *

Kindergarten

1st

2nd

3rd

4th

5th

5. Is your student experiencing any of the following symptoms? Check all that apply. PLEASE NOTE: If your student's symptoms all resolve within 48 hours, they may return to school. If your child had a fever of 100.4 or above, they will need to be fever free for 24 hours without the use of fever-reducing medication. Your student will need to remain home for 24 hours after the last episode of vomiting or diarrhea. If symptoms do not resolve within 48 hours, please refer to CDPHE's Return to Learn guidance: https://drive.google.com/file/d/1nhgGIbakyAJY3XJ2TW44sw7btXXqISBR/view *

Cough

Sore throat

Runny nose or congestion

Headache

Nausea, vomiting or diarrhea

Muscle or body aches, chills

Fatigue

Shortness of breath or difficulty breathing

Fever of 100.4 or higher

New loss of taste or smell

None of the above

Required

6. If symptoms were present, on what date did they first begin?

YYYY

7. If your student has been or will be tested for COVID-19, indicate date of test.

YYYY

8. If a COVID-19 test was done, what were the results? If positive, student should isolate for at least 5 days from date of symptom onset or test date, if asymptomatic which is day 0. If symptoms are improving or gone and student has not had a fever in the past 24 hours, they may return on day 6 and must wear a mask around others for 5 additional days.

Positive: may skip to question 12

Negative

Pending: Please complete this form again when the results of the test are known.

Clear selection

9. Has your student been exposed to COVID-19 outside of school?

Yes, my student was exposed and has isolated from the positive individual

Yes, my student was exposed and is not able to isolate from the positive individual - please contact your school for a return date

No, skip to question 12

Clear selection

10. Does your student meet any of the following criteria: Is fully vaccinated for COVID-19 (it has been more than 14 days since their second dose) AND/OR Had a confirmed case of COVID-19 in the past 90 days.

Yes and asymptomatic: no quarantine is needed but isolate and test if symptoms appear

No: Stay home for at least 5 days after your last contact with a positive individual.

Clear selection

11. If your student has been exposed and the exposure has stopped, what was the last date of exposure? This is considered day 0.

YYYY

12. If you are aware of your student's return to school date, please enter here. If unsure, leave blank and you will be contacted by school staff

YYYY

13. Please list your best email for school staff to contact you.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lps.k12.co.us. Report Abuse

Forms