Education Infection Control Form

Education Infection Control Form

Purpose: To document current health status, recent exposures, immunization and testing history, medical conditions, and consent for school infection-control actions necessary to protect the student population. Completion of this form enables school health staff to evaluate risk, implement exclusion or isolation measures, and communicate necessary information to health personnel in accordance with applicable public health requirements.

Student Information

Date of Birth:   Student ID:

Primary Phone:   Email:

Parent / Guardian Information

Relationship:   Phone:

Emergency Contact Phone:

Medical History and Conditions

Please indicate applicable medical conditions (check all that apply):

Asthma or chronic respiratory disease
Diabetes
Immunocompromised condition
Pregnancy
None of the above

Current Symptoms and Recent Illness

Symptom checklist (check all current symptoms):

Fever (measured or subjective)
New or worsening cough
Shortness of breath or difficulty breathing
Sore throat
Loss of taste or smell
Vomiting or diarrhea
Skin rash
No current symptoms

If symptomatic, date symptoms began:

Exposure, Travel, Immunization and Testing

Has the student had known close contact with a person diagnosed with a communicable infection within the past 14 days? Yes No

Travel outside the local area within the past 14 days: Yes No

Immunization status (check boxes and provide dates where known):

Influenza up to date   Date:
COVID-19 vaccination up to date (if applicable)   Date:
MMR up to date   Date:
Varicella up to date   Date:

Test date:   Result: Positive Negative Pending

Medications and Allergies

Consent and Acknowledgment

By signing below I certify, under penalty of perjury, that the information provided on this form is true and complete to the best of my knowledge. I authorize school health personnel to take reasonable infection control actions on behalf of the student, which may include exclusion from school activities, temporary isolation, collection of diagnostic specimens, and emergency treatment when necessary. I further authorize release of health information provided herein to authorized school staff and to public health authorities when required by law.

I understand that exclusion or readmission decisions will be made in accordance with established school infection control policies and applicable public health guidance. I accept responsibility to notify the school if the student's condition changes or if the student receives a positive diagnostic test for a communicable infection listed above.

Consent (select all that apply):

I consent to temporary isolation of the student at school if required for infection control.
I consent to diagnostic testing of the student while at school if clinically indicated.
I consent to disclosure of pertinent health information to school health staff and public health authorities as needed.
I consent to emergency treatment should the student require immediate medical attention while under school supervision.

Acknowledgment of School Infection Control Policies

I acknowledge that the school may implement measures consistent with infection control best practices, which may include targeted cleaning, communication to contacts of confirmed cases, and temporary modification of in-person activities. The school will endeavor to protect privacy consistent with legal requirements; however, I understand that some disclosures to appropriate personnel or authorities may be required.

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