Release from Quarantine due to SCHOOL exposure

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Medical Clearance/Return to School after Quarantine due to a COVID-19 School Exposure

Any student placed in quarantine due to a school exposure is required by the Orange County Department of Health to have medical clearance to return to school. You may have your personal doctor send in this clearance, or you may complete a screening attestation. The screening must be done WITHIN 24 HOURS OF YOUR RETURN to school via this Google Survey Form (You may request a hard copy from your school nurse.). This release from quarantine must be completed by the parent/guardian of the student in quarantine. This form is only accepted if your quarantine was because of a school exposure. Any student who tested positive for COVID-19 or who was placed in quarantine for an exposure outside of school, must still get medical clearance from their personal healthcare provider.

Email *

First Name *

Last Name *

Date of Birth *

YYYY

Middle School Grade *

Date placed in precautionary quarantine *

YYYY

Date release from precautionary quarantine *

YYYY

During my quarantine period I have NOT had one or more of the following symptoms: Temperature greater or equal to 100.0 F (37.8 C), Feel feverish or have chills, Cough, Loss of taste or smell, Fatigue/feeling of tiredness, Sore throat, Shortness of breath or trouble breathing, Nausea, vomiting, diarrhea, Muscle Pain or body aches, Headaches, Nasal congestion/runny nose (if False - do NOT return to school and call your school nurse). *

True

False

I have NOT had a positive COVID 19 test (in past 14 days) NOR am I currently waiting for the results of COVID 19 test (if False - do NOT return to school and call your school nurse). *

True

False

I attest that I have quarantined from the date I was alerted through the end of my 10 days Order of Quarantine. (if No - do NOT return to school and call your school nurse). *

Yes

I attest that all questions have been answered accurately. My written, full name is to serve as an electronic signature (TO BE COMPLETED BY PARENT/GUARDIAN). I understand I may be screened by the Health Office upon my return to the building. *

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

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