St M Illness Reporting Form
For the health and safety of all of our students, faculty, and staff, thank you for informing St. Michael's if your child is ill and/or has a suspected contagious illness.  Please complete this form from the perspective of the student (or faculty/staff member) who is ill.

Our nurse office hours are 8 a.m. to 3 p.m., Monday through Friday. If you submit the form outside of these hours, Nurse Maben will follow up the next business morning.  For questions, please contact Nurse Maben at smaben@stmschool.net.  Thank you! 
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Email *
Full name of the STUDENT: *
STUDENT Grade: *
Required
Full name of parent/guardian: *
Contact number for parent/guardian *
What is the primary purpose of submitting this form today? (e.g. flu, lice, strep throat, COVID-19, pink eye, impetigo, etc.) *
If selected "other" in question above, please list illness/medical concern.
When did the symptoms begin? *
MM
/
DD
/
YYYY
Is there any additional information we should know?
Do you carpool with any St. Michael's families? If so, please list names.
A copy of your responses will be emailed to the address you provided.
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