RETURN TO SCHOOL FORM

Day School Administration will complete this form to provide to parents when picking up children who have
developed symptoms while at school.

Parents are required to provide the completed form to Day School Administration prior to return.

SECTION A: SYMPTOMS OF COVID-19

To be completed by Day School Administration when sending child home or Parent/Guardian if symptoms
developed at home:
Child Name: Date of Onset:

Symptoms:

Name of Day School Administrator or Parent completing form:

SECTION B: SELF-QUARANTINE
To be completed by Parent/Guardian if declining medical assessment or testing for COVID-19.

Any unspecified diagnosis is presumed to be COVID-19 and the 10 day exclusion period is required.
Ten days have passed since my household first experienced symptoms; and
Symptoms have improved for anyone in the household who experienced symptoms; and
No new symptoms have developed.
Household has been fever-free for at least 24 hours without the use of fever-reducing
medications.

Parent Signature Date

SECTION C: INDEPENDENT PCR TEST

To be completed by Parent/Guardian if PCR test completed independent from medical assessment.
A negative PCR test result has been received and submitted to Day School Administration.
Diagnostic Lab Conducting Test:

Date of Test: Phone Number:

Date Results Submitted to Day School: Email Fax

Parent Signature:

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SECTION D: MEDICAL RELEASE
To be completed by a Physician.

The individual named above has been under my professional care and has been medically evaluated.
Please check all that apply:

Alternate Diagnosis - I have diagnosed the patient with a non-COVID illness or condition which
causes the symptoms described above. The patient may return to child care/work (as
applicable) subject to the following non-COVID return requirements:

Negative COVID-19 Test - Date of Test__________

The patient was symptomatic and tested negative for COVID-19 using a molecular or antigen
test for SARS-CoV-2. The patient is cleared to return to child care/work (as applicable) when
fever-free for 24 hours (without the use of fever-reducing medication) and the presenting
symptoms have improved.

Physician Statement:
I understand that HPUMC Day School will rely on my statement to allow the patient to enter
and/or attend an early childhood education program serving Infants through Pre-Kindergarten.

Physician Name:

Practice Name:

Phone Number:

Signature: Date:

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