________________ PUBLIC SCHOOLS
_____________, Connecticut
ILLNESS REPORT
Date:__________________________
Student Name: _________________________________________________ Grade: ________
Secretaries: Please ask the following questions when a parent/guardian calls into the school stating that their student will not be attending on a regularly-scheduled school day DUE TO ILLNESS ONLY. Please fill in and check the appropriate answers. Thank you.
1. Is your student ill? ___ YES ___NO
Describe Symptoms:_______________________________________________________
________________________________________________________________________
2. Do they have a fever? ___YES ___NO
How high? _______________________________
3) Contact Name____________________________________________________________
4) Telephone Number: _______________________________________________________
The Health Office Nurses may call you back to obtain more details. This is a precautionary measure our school is taking due to potential contagious diseases. Thank you.
(Please submit this form to the Health Office and include the daily absence list.)
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