6114.8  Form #1

________________ 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.)

*   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *  *