Return to Therapy Following Illness Certification Form

Please put a check next to each statement indicating agreement (required)

1) It has been at least 3-days (72 hours) since my child has had a fever (100.4° F or higher) without the use of fever-reducing or other symptom-altering medicines (e.g., cough suppressants)

2) My child has not exhibited respiratory symptoms related to COVID-19 (coughing or shortness of breath) in the past 72 hours without the use of symptom-altering medicines (e.g., cough suppressants)

3) My child has not exhibited any other symptoms (e.g., loss of taste or smell, gastrointestinal problems, such as nausea, diarrhea, and vomiting) in the past 72 hours without the use of symptom-altering medicines

4) At least 7 days have passed since my child's COVID-19 symptoms first appeared.
Date symptoms first appeared:

5) My child has not been in close contact with anyone who has exhibited any COVID-19 symptoms or tested positive for COVID-19 in the past 7 days. *Close contact means living in the same household or being within six feet of a person for 15-minutes

6) Date to return to therapy:

Please attach Doctor's note: