Health Room

Report Absence

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Parent Name *

Absent Student Name *

Do you want classwork to be sent home? *

Yes

Who would you like classwork sent home with?

Is your child experiencing any of the following Symptoms? *

	Yes	No
Do you have a new fever (100.4 or higher), or a sense of having a fever? *	Do you have a new fever (100.4 or higher), or a sense of having a fever? - Yes	Do you have a new fever (100.4 or higher), or a sense of having a fever? - No
Do you have a new cough that you cannot attribute to another health condition? *	Do you have a new cough that you cannot attribute to another health condition? - Yes	Do you have a new cough that you cannot attribute to another health condition? - No
Do you have new shortness of breath that you cannot attribute to another health condition? *	Do you have new shortness of breath that you cannot attribute to another health condition? - Yes	Do you have new shortness of breath that you cannot attribute to another health condition? - No
Have you lost any sense of smell or taste? *	Have you lost any sense of smell or taste? - Yes	Have you lost any sense of smell or taste? - No
Do you have new muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise)? *	Do you have new muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise)? - Yes	Do you have new muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise)? - No
Do you have a new sore throat that you cannot attribute to another health condition? *	Do you have a new sore throat that you cannot attribute to another health condition? - Yes	Do you have a new sore throat that you cannot attribute to another health condition? - No
Are you suffering from fatigue that you cannot attribute to another health condition? *	Are you suffering from fatigue that you cannot attribute to another health condition? - Yes	Are you suffering from fatigue that you cannot attribute to another health condition? - No
Do you have a headache that you cannot attribute to another health condition? *	Do you have a headache that you cannot attribute to another health condition? - Yes	Do you have a headache that you cannot attribute to another health condition? - No
Do you have congestions or a runny nose that you cannot attribute to another health condition? *	Do you have congestions or a runny nose that you cannot attribute to another health condition? - Yes	Do you have congestions or a runny nose that you cannot attribute to another health condition? - No
Are you experiencing nausea, vomiting or diarrhea? *	Are you experiencing nausea, vomiting or diarrhea? - Yes	Are you experiencing nausea, vomiting or diarrhea? - No
Have you had any close contact with a person that has a suspected or confirmed case of COVID-19 or demonstrated any of the above symptoms? *	Have you had any close contact with a person that has a suspected or confirmed case of COVID-19 or demonstrated any of the above symptoms? - Yes	Have you had any close contact with a person that has a suspected or confirmed case of COVID-19 or demonstrated any of the above symptoms? - No

If your child is not experiencing any of the previous symptoms, please explain your absence.

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Nurse Sarah Dalton

Nurse Dalton

School Nurse

Medical Forms

Decision Tree