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Lineham After-Illness Return Attestation
This attestation can be completed by a parent/guardian or a staff member. It does not need to be completed by a healthcare provider.
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* Indicates required question
Name of student/staff:
Your answer
Date of birth:
MM
/
DD
/
YYYY
Phone number:
Your answer
School/program name:
Your answer
Please provide dates of absence
*
Your answer
Please check all symptoms that apply. If your child had any ONE of the following symptoms you must be tested for COVID-19.
Cough - Must be tested for COVID-19
Shortness of breath or difficulty breathing - Must be tested for COVID-19
Loss of taste - Must be tested for COVID-19
Loss of smell - Must be tested for COVID-19
Please check all symptoms that apply. If your child had any TWO of the following symptoms you must be tested for COVID-19.
Fever (temperature higher than 100.4 or felt feverish to the touch)
Chills
Muscle or body aches
Headache
Sore throat
Fatigue
Congestion or runny nose
Nausea or vomiting
Diarrhea
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