K-12 SCHOOLS SYMPTOM SCREENING: Parent/Guardian Attestation

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Email *

Child's First Name *

Child's Last Name *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Has your child had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine? *

Yes > The child should not be at school. The child can return 14 days after the last time he or she had close contact with someone with COVID-19, or as listed below.

No > The child can be at school if the child is not experiencing symptoms.

Does your child have any of these symptoms? *

If a child has any of these symptoms, they stay home, stay away from other people, and you should call the child’s health care provider.

Fever

Chills

Shortness of breath or difficulty breathing

New cough

New loss of taste or smell

N/A (If no symptoms)

Required

Since they were last at school, has your child been diagnosed with COVID-19? *

If a child is diagnosed with COVID-19 based on a test, their symptoms, or does not get a COVID-19 test but has had symptoms, they should not be at school and should stay at home until they meet the criteria below.

Yes

A child can return to school when a family member can ensure that they can answer YES to ALL three questions: *

Has it been at least 10 days since the child first had symptoms?

Has it been at least 3 days since the child had a fever (without using fever-reducing medicine)?

Has it been at least 3 days since the child’s symptoms have improved, including cough and shortness of breath?

Required

Return to School

If a child has had a negative COVID-19 test, they can return to school once there is no fever without the use of fever-reducing medicines and they have felt well for 24 hours.

If a child has been diagnosed with COVID-19 but does not have symptoms, they should remain out of school until 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test.

If a child has been determined to have been in close contact with someone diagnosed with COVID-19, they should remain out of school for 14 days since the last known contact, unless they test positive In which case, criteria above would apply They must complete the full 14 days of quarantine even if they test negative.

I attest that the following information is true to the best of my knowledge as of: *

YYYY

I attest that the following information is true to the best of my knowledge as of: *

Time

By typing my name below, I attest that the above information is true to the best of my knowledge: *

Send me a copy of my responses.

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