Absence Report Due to Illness or COVID related issue (ie; close contact positive, waiting on a test, etc.)

O JavaScript não está habilitado em seu navegador. Em função disso, não é possível abrir este arquivo. Habilite o JavaScript e atualize a página.

This form will be used to report a student's absence from school to the health office at New Covenant Academy. (One form per student must be completed). Depending on how you answer these questions, you may receive a follow-up call from one of NCA's nurses.

Faça login no Google para salvar o que você já preencheu. Saiba mais

E-mail *

Today's Date *

AAAA

Student Last Name *

Student First Name *

Grade *

Teacher or Division Name *

When did you first notice symptoms (If no symptoms put today's date) *

AAAA

Symptoms-Check all that apply *

Cough

Diarrhea

Excess tiredness

Fever>=100F

Headache

Muscle aches

Nasal congestion

Nausea

Runny nose

Shortness of breath

Sore throat

Vomiting

None of the above

Obrigatória

Provide any additional symptoms not noted above

Optional: You may use this space to explain to NCA's health office what is going on with your child.

Have you consulted a doctor about this illness? *

Yes

If you answered "No" to the above question, do you plan on consulting a doctor for this illness?

Yes

Limpar seleção

Full Name of the individual completing this form *

What is your relationship with the student? *

Mother

Father

Step-Mother

Step-Father

Grandparent

Guardian

Outro:

What is the best phone number that our Health Office personnel can reach you at, should they need to follow-up with you? *

Enviar uma cópia das respostas para o meu e-mail.

Enviar

Limpar formulário

Nunca envie senhas pelo Formulários Google.

reCAPTCHA

Privacidade Termos

Este formulário foi criado em New Covenant Academy. Denunciar abuso

Formulários