Return to School Evaluation Form/Covid Exposure Information Form

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Email *

Please type your first and last name. *

Are you reporting an illness that caused you to miss school, symptoms that have occurred at home, or an exposure to COVID 19 for someone is your household? *

Illness where I missed school

Symptoms of illness that I had at home, but have not missed school. Should I come to school?

I have been exposed to COVID-19 by someone in my household

Other:

Name and date of illness or exposure-Description of illness you experienced in your own words. *

During your illness, or since exposure, did you have any or all of the following. Click on any of the symptoms that you experienced. Clicking yes does not prevent you from returning to school. It allows the school personnel to make an accurate assessment of your risk to return. *

Yes

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

New congestion or runny nose

Nausea or vomiting

Diarrhea

Fever of 100.4 or higher

Have you been recommended to be in quarantine by a healthcare professional? *

Who gave you the recommendation? *

For an absence due to an exposure, we will verify the quarantine recommendation through the health department. Do you give us permission to obtain this verification, so you don't have to? *

Yes

Quarantine procedures are different for vaccinated individuals. Are you currently vaccinated, and are you willing to share your record, if you have not already. Click no if you are vaccinated and are not willing to share the record. You will be addressed as an unvaccinated person. Thank you. *

Yes

A copy of your responses will be emailed to the address you provided.

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