Parent/Guardian Health Screening Commitment Form

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To protect our children and staff, I commit to complete a daily health screening of my child using the COVID-19 Health Screening Questions and to not send my child to school when he/she is sick or feeling unwell with the symptoms consistent with COVID-19. This commitment will apply to all school-age children in my home.

Email *

Child's Last Name *

Child's First Name *

Date of Birth *

YYYY

Child's Grade Level *

I agree to screen all school-aged children in my home each day prior to sending him/her to school and agree to keep my child at home if he/she...(Please check to acknowledge each.) *

...is feeling feverish and/or having chills (if documented temperature/fever of 100.4 or greater)

...has a new cough not due to another health condition

...has fatigue (more tired than usual)

...has nasal congestion or runny nose

...has a headache

...has a new sore throat not due to another health condition

...has new chills not due to another health condition

...has new muscle pain not due to another health condition or that may have been caused by a specific activity such as physical exercise

...has new loss of taste or smell, new onset of poor appetite or poor feeding

...has abdominal pain, diarrhea, nausea, vomiting

Required

I understand that the COVID-19 Health Screening Questions may change over time as required by the Centers for Prevention and Disease Control (CDC) and that Fairfax County Public Schools (FCPS) will update the health screening questions, as required. FCPS will communicate any necessary changes to me. *

I agree to continue daily health screenings based on the current requirements

I agree not to send my child back to school if he/she has any of these signs of COVID-19 until (Please check to acknowledge each): *

My child tested negative for COVID-19 and is otherwise well enough to go back to school OR...

...A healthcare provider has seen my child and documented a reason for the symptoms other than COVID-19 OR...

...All are true: 1) AT LEAST 10 days since the start of symptoms AND 2) fever-free off anti-fever medicines for 24 hours AND 3) symptoms are getting better.

Required

I agree not to send my child back to school if he/she is diagnosed or confirmed with COVID-19, until the following are met (Please check to acknowledge each): *

It has been AT LEAST 10 days since my child first had symptoms AND...

...My child has had no fever off anti-fever medicines (ex: Tylenol, Ibuprofen) for 24 hours AND

...My child's symptoms are getting better

Required

I agree to take my child to a physician for evaluation and completion of the Permission to Return to School/Child Care each time my child is sent home ill during the school day. *

I agree

If someone in my household has been diagnosed or confirmed with COVID-19, or my child is exposed (*Exposure is defined as individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total for 15 minutes)... *

...I agree to keep my child home for 14 days after their last exposure to the household member.

If someone in my household develops any of the above symptoms, I will get that person evaluated by a health care provider and/or tested for COVID-19. If that person tests positive or is diagnosed with COVID-19, I will keep my child home for 14 days after their last exposure to this household member OR as above if my child tests positive. *

I agree.

My name below serves as my signature to confirm my commitment to the agreements above. *

I committed to the Parent/Guardian Health Screening practices on... *

YYYY

Send me a copy of my responses.

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