ILLNESS REPORT Child’s Name:
Age:
Was being observed for possible illness. (see documentation below) Is being sent home today for the following reason(s): (see list of symptoms) Children’s Center WAC 170-295-3030 (1): Your staff must check all children for signs of illness when they arrive at the center and throughout the day. (2): You must exclude children and staff with the following symptoms from care:
Diarrhea (three or more watery stools or one bloody stool within 24 hours)
Incident times:
Vomiting (two or more times within 24 hours)
Incident times:
Open or oozing sores, not properly covered with cloths or with bandages
For suspected communicable skin infection such as impetigo, pinkeye, and scabies. (Your child may return 24 hours after starting antibiotic treatment)
Lice or nits
Fever of 100º degrees Fahrenheit or higher and who also have one or more of the following:
Earache
Fatigue that prevents participation in regular activities.
Headache Sore throat
Comments/Observations:
Treatment provided while in care:
Names of staff providing treatment:
Yes No To be determined Was this reported to family/guardian? Yes No How? Verbal Phone Email Other Was the child’s physician contacted?
Time?
By Whom?
Teacher/Staff Signature:
Person Contacted Date:
Time:
I have been notified and agree my child may return to Kids First Children's Center when:
I bring written authorization from a Health Care Provider – OR – My child remains away from child care and symptom free for a minimum of 24 hours. I understand that staff must check my child for signs of illness upon returning to the center.
Family/Guardian Signature: White: Center copy
Yellow: Family copy
Date:
Time: Revised January 2012