Student COVID-19 Self Certification

Student COVID-19 Self-Certification and Verification Form

*Must be Signed by Parent/Guardian prior to Student’s First Day of School Attendance
In response to the COVID-19 pandemic and to ensure a safe and healthy environment for our school community, the District is implementing prevention strategies, which include a daily symptom screening for each student prior to entering any School District building. Parents/Guardians must conduct this daily symptom screening prior to their student departing for school and report consistent with the parameters outlined below. This form must be signed and submitted to the School District prior to the student’s first day of school attendance.  This form needs to be submitted only one time for each student.

Certification and Verification of Daily Symptom Screening: I verify that my student received a daily symptom screening at home by an adult caregiver to determine if my student is experiencing any of the following COVID-19 symptoms:

·        Fever (100.4 or higher)

·        New* cough

·        Shortness of breath/difficulty breathing

·        Fatigue from unknown cause

·        Muscle or body aches from unknown cause

·        New onset of moderate to severe headache

·        Sore throat

·        Congestion/runny nose

·        New loss of sense of taste or smell

·        Nausea or vomiting

·        Diarrhea

·        Any other COVID-19 symptoms

*According to the IDPH, the reference to “new” means new onset of a symptom not attributed to allergies or a pre-existing condition.

By sending my student on District transportation and/or to school on any given day, I am certifying and verifying that my student has received a daily symptom screening at home and is not experiencing any COVID-19 symptoms. If my student is experiencing any of the above symptoms at the time of the daily screening, I will notify the school of my student’s absence by sending an email to the school nurse, Ms. Tracy Steffes, at tsteffes@morrishs.org and indicating the above symptoms that my student is experiencing. If District staff contacts me to gather additional information related to the results of my student’s daily screening, I will provide the necessary information as requested.

By sending my student on District transportation and/or to school on any given day, I am also certifying and verifying that my student is not subject to an isolation or quarantine protocol related to COVID-19.

Morris Community High School
Student Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Grade Level *
6-Digit Student ID Number
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Signature *

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Student COVID-19 Self-Certification and Verification Form