• Return to School Clearance Form - COVID-19 (Printable PDF)

     

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    ELMONT SCHOOL DISTRICT

    Elmont, New York

     

    RETURN TO SCHOOL CLEARANCE – COVID-19

     

    Please have your Health Care Provider (HCP) complete this document to return to school. Please have your child seen by a Health Care Provider (HCP) within 48 hours of this request.

     

    Student’s Name: ___________________ DOB: _______/_______/________

     

    Date sent home from school:  _______/_______/________

     

    Student’s symptom(s): ___________________________________________

     

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    Health Care Provider:  Please fill out this section.

     

    Date of first symptom:  _______/_______/_______             Type of COVID test: 

                                                                                                              square PCR   

                                                                                                              square Antigen/Rapid

                                                                                                    Results: 

                                                                                                               square Not Done

                                                                                                               square Positive

                                                                                                               square Negative

                                                                                                               square Pending

     

    The earliest this student may return to school is: _______/_______/________

     

    Please select one:

     

    _______Student tested NEGATIVE for COVID-19 as stated above. Student has been fever-free (without using fever-reducing medicine) for 24 hours and student’s symptoms are improving, or symptoms are resolved for 24 hours. The patient is now cleared by the undersigned HCP to return to school per NYS DOH and NYS DOE guidance.

     

    _______Student presented to our office with symptoms that could be consistent with COVID-19 infection. Student was NOT TESTED for COVID-19 infection. It has been at least 10 days since student first had symptoms. The student has been fever-free (without using fever reducing medicine) for 72 hours and has had improving symptoms for 72 hours. The student is now cleared by the undersigned HCP to return to school per NYS DOH and NYS DOE guidance.

     

    _______Student tested POSITIVE for COVID-19 as stated above. It has been at least 10 days since the student first had symptoms. The student has been fever-free (without using fever reducing medicine) for at least 72 hours and it has been at least 72 hours since his/her symptoms improved including cough and shortness of breath. The student is now cleared by the undersigned HCP to return to school per NYS DOH and NYS DOE guidance.

     

    _______ Student has been evaluated and diagnosed with ________________ on ________/________/________.  The student has been fever-free, without the use of fever-reducing medicine for 24 hours and student’s symptoms are improving, or symptoms are resolved for 24 hours. The student is now cleared by the undersigned HCP to return to school per NYS DOH and NYS DOE guidance.  

    Note: a signed HCP note documenting unconfirmed acute illnesses, such as viral upper respiratory illness (URI) or viral gastroenteritis, will require a COVID-19 test.

     

    Health Care Provider’s Name: _____________ Date: _______/_______/_______

     

    Health Care Provider’s Signature: _________________________ Stamp: