Self Screener Exclusion Request Form

Self Screener Exclusion Request

Submission of this form is only necessary if you can answer "yes" to one of the questions below. Please submit this form as soon as you are able, if you answer "yes" to any of the home screener questions. For assistance submitting the form, please contact your school office.
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
School
Daily Home Screener

If you answer YES to any of these questions, you should not come to school and should complete this exclusion form to make us aware of your health status or concern.
1. Have you been in close contact with someone who has a lab-confirmed case of COVID-19 in the past 14 days or been advised by a health care official to self quarantine or isolate?
2. In the past 48 hours, have you experienced any of the following NEW symptoms:
  - Fever of 100.4° or above
  - Cough
  - Sore Throat
  - Muscle pain
  - Chills or Repeated Shaking with Chills
  - Shortness of breath, Trouble Breathing or Severe Wheezing
  - Loss of Smell or Taste, or a Change in Taste
  - Nausea, vomiting, or diarrhea
3. Have you recently been in close contact with anyone who has exhibited any symptoms or tested positive for COVID-19?
4. Have you recently traveled out of state or internationally to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department?
Which of the above questions can you answer "yes" to? *
Multiple selections allowed. Remember you do not need to submit this form unless you can answer yes to one of the above 4 questions.
Please provide any necessary explanation for your selection. Also, include any discussions you have had with your doctor or the health department about your status.
Upon submission, a representative from Shelby Eastern Schools will review your submission and contact you with guidance about the next steps you should take. Please do not come to school until we have contacted you and advised you to do so.
Should be Empty: