Illness Assessment & Return to School Form

Illness Assessment & Return to School Form
Illness Assessment & Return to School After Illness Requirements
Dear Parent/Guardian of : _______________________________ Date:____________
New York State Department of Health (NYSDOH) guidelines require that any student who has
potential COVID-19 symptoms be sent home.
Your child has presented to the Health Office with the following symptoms:
Fever/Chills - Temperature__________ Cough Shortness of Breath
Nausea/Vomiting/Diarrhea Fatigue Rash
New loss of taste or smell Headache Nasal Congestion
⁢ Muscle of body aches Sore throat Decreased appetite
School Districts must follow NYSDOH guidelines that allow students to return to school after
being sent home for exhibiting symptoms consistent with COVID-19 or after being diagnosed
with COVID-19.
Your child may return to school when the following are met:
Documentation from a Health Care Provider with a specific alternate diagnosis or chronic
medical condition without new or worsening symptoms clearing student to return to school
without a COVID – 19 test is provided OR
A confirmed negative COVID-19 test AND
No longer having symptoms of COVID-19 (fever free without fever reducing medications for
over 24 hours) AND
If COVID-19 positive, release from isolation from the Your County Department of Health
It is recommended that you reach out to your child's Health Care Provider as soon as possible
for symptoms that worsen and for guidance on returning to school. Local Health Care Providers
and school districts will be working closely with the County Health Department for guidance and
requirements to determine when a student can return to the learning environment.
We encourage you to reach out to the School Nurse with any updated information from the
Health Care Provider as necessary. Notes from Health Care Providers allowing your student to
return to school MUST be provided prior returning to school or riding the bus. Health Care
Provider notes can be dropped off to the School Nurse, emailed or faxed.
Lisa Sauer – Middle/High School Nurse
Email -
Fax# - 585-584 -3421
Liz Milligan – Elementary School Nurse
Email –
Fax# - 585-584-1050
Your signature below indicates you understand the return to school requirements and
when your child can return to school.
___________________________/ ___________________________ /________
Parent/Guardian Signature School Nurse Signature Date