Gesu Communicable Disease Notification

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Please answer the following questions related to a student who has a communicable disease. We are required to notify families of various contagious diseases. Please complete one form per student. This form will be viewed only by the Gesu School Nurse and Gesu Administration.

In addition to completing this form, please call the attendance line to report your child absent.

Student Name (First and Last) *

Grade *

Homeroom or Teacher

Illness

Chickenpox (Varicella)

COVID-19 (SARS-CoV-2)

Fifth Disease (Erytherma Infectiosum)

Hand Foot and Mouth (Coxsackie)

Impetigo

Lice (Head Lice, Pediculosis)

Meningitis Viral/Aseptic

Meningitis Bacterial

Pink Eye (Conjunctivitis, Bacterial or Viral)

Pinworms

Ringworm

Strep Throat (Streptococcal Infections)

Scabies

Whooping Cough (Pertussis)

Other:

Clear selection

Date of test or diagnosis *

YYYY

Last date in school *

YYYY

Notes from Doctor

Questions or Comments

Submit

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