Tobias Student Injury and Illness Questionnaire
This questionnaire is to help capture more accurate illness numbers on campus so my weekly reports to county are more accurate.  Per district policy, a student with fever 100 or higher, vomiting, or diarrhea must remain home until 24  hours free of those symptoms without the use of fever reducing or diarrheal illness medications. Begin 24 hour count 6-8 hours AFTER the last dose is given. Please follow physician guidance on return to school from injury or illness.  Please forward any test results/doctor's note clearing for return.  Please email your school nurse at Ashley.Armstrong@hayscisd.net if you have any questions or other concerns.  **The information gathered with this form is private and protected and not shared with anyone other than TES attendance and Tobias staff on a need to know basis. 

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Student Full Name *
Homeroom teacher *
Grade *
My child is experiencing a/an *
Required
Please describe symptoms or situation
Date missed for symptoms above *
MM
/
DD
/
YYYY
My child was diagnosed with ... (please forward any test results/doctor's note clearing for return). Any condition requiring antibiotics, student must remain home until 24 hours after the first dose.  *
Required
Parent name *
Do you have any other questions or concerns for the school nurse?
Best phone number to reach you at
Best email address
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