View or download this form as a PDF: Suspected COVID Go Home Form
Name: ______________________________ Grade: _____ Date: _____________ Time: ________
The following has presented to the School Nurse with the following symptoms that are consistent with COVID-19:
Fever of ________ Cough____ Shortness of breath or difficulty breathing____Fatigue/Tired____ Muscle/Body Aches____ Headache____ New loss of taste or smell____Sore throat____Congestion or runny nose____ Nausea/vomiting/Diarrhea____ Other: _______________________________________________________________
Per NYSDOH students/staff, MUST be seen by a medical provider and COVID-19 test results must be received within 48 hours. After 48 hours, the symptomatic individual will be deemed POSITIVE for COVID-19 per NYSDOH.
A NEGATIVE COVID – 19 DIAGNOSIS
HAS SYMPTOMS OF POSSIBLE COVID-19 ILLNESS, BUT IS DETERMINED NOT TO HAVE COVID-19 BY A HEALTH CARE PROVIDER (MD, NP, Physician Assistant) CAN RETURN TO SCHOOL WHEN
B POSITIVE COVID – 19 DIAGNOSIS
IS DIAGNOSED WITH COVID-19 BY A HEALTH CARE PROVIDER BASED ON A TEST OR THEIR SYMPTOMS, THEY SHOULD NOT BE AT SCHOOL AND SHOULD STAY HOME UNTIL:
A note from the health care provider stating you are cleared to return to school, along with the formal email release or letter of release of quarantine from Public Health is required. SMS text message release of quarantine is not acceptable. All documentation MUST be given to the School Nurse BEFORE riding the bus or entering the building.
Contact your health care provider as soon as possible for guidance and if any symptoms become worse, CALL 911.