COVID Reporting Form

Student Illness Reporting Form

Newmeadow is required to report to the Department of Health any suspected or confirmed communicable diseases within the school. Examples include, but are not limited to, COVID, Flu, RSV, etc. For a full list please refer to form DOH-389 (1/24) pg 2. Additionally, while individual cases of some diseases are not reportable, a cluster or outbreak of cases of any communicable disease is a reportable event. A cluster/outbreak includes two (2) or more cases in a classroom or five (5) or more cases throughout the school. Examples include, but are not limited to, streptococcal sore throat, head lice, impetigo, coxsackie, scabies, and pneumonia. To help us meet the reporting requirement we ask that you please complete the following form. The reporting of communicable diseases is for tracking purposes only. You will not be contacted by the Department of Health. If you have any questions please contact the health office at 518-899-9235. Thank you.

Student Name:*

First

Last

Student Date of Birth:*

day

month

year

Parent/Guardian Name:*

First

Last

Parent/Guardian Email:*

Parent/Guardian Phone #:*

Student Address:*

Street Address City State / Province / Region Postal / Zip Code

County where student resides?*

School Location*

Clifton Park

Fort Edward

Assigned classroom:*

Does student attend aftercare in Clifton Park? (Mark N/A if not applicable)*

Yes

Information regarding illness:*

Diagnosis:

Date of diagnosis:

Last day student attended school:

Additional information (if needed)

Thank you for completing the Student Illness Reporting Form.

The information provided on this form will only be shared with the Department of Health (as required).

Please contact the health office if you have any questions/concerns.

Thank you.

If your child has a doctors note, you may upload it here.

Locations

Business Office

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