* Required

Parents/Guardians: Please complete this short checklist to report your child’s absence and symptoms. Please complete a new form for each child in your house that attends SRDS. Questions? Please contact Nurse Ann Hanna (201) 327-4050 x2911 or ahanna@saddleriverday.org

Student Name*required

Grade*required

Date*required (mm/dd/yyyy)

Parent/Guardian Name*required

Parent/Guardian Email*required

Section 1: Symptoms

Any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child daily for these symptoms:

Symptoms Checklist

Check all the apply

Fever Cough Difficulty Breathing Muscle or body aches Sore Throat Nausea Vomiting Diarrhea Loss of Taste Stomachache Headache Fatigue Congestion

Section 2: Close Contact/Potential Exposure

*Area of high community transmission

Potential Exposure Checklist

Please verify if

Your child has had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19 Someone in your household is diagnosed with COVID-19 Your child has traveled to an area of high community transmission* (See above).

If ANY of the fields in Section 2 are checked off, your child should remain home for 14 days from the last date of exposure (if child is a close contact of a confirmed COVID-19 case) or date of return to New Jersey.

Contact your child’s provider or your local health department for further guidance.

Please send a confirmation email to the address below*: