Reporting Form for Absenteeism Over 20%

Edited for Jolene Bracale by Don Gilroy on 02/21/2023.
Reporting Form for Absenteeism Over 20%
Name of School:*
Name of School Corporation:*
County*
Date:*

MonthDayYear
Total Number of Students Enrolled in School: *
Total Number of Students Absent: *
Known Diagnosis:*

Influenza AInfluenza BCOVIDStrep ThroatNorovirusUnknownOther
Local Health Department has been Notified: *

YesNo
Plan of Action - School Will:*

Remain OpenRevert to a Virtual Learning DayClose with No Instruction Provided
Title of Person Completing Report*

RNLPNHealth Aide (HA)School AdministrationSchool Office Staff
Should be Empty: