MBSA Student Absentee Form










If you selected "Other" please specify

If you selected "Illness" please specify

Fever or Chills:
YesNo

Cough:
YesNo

Shortness of breath or difficulty breathing:
YesNo

Fatigue:
YesNo

Muscle or body aches:
YesNo

Headache:
YesNo

New loss of taste or smell:
YesNo

Sore throat:
YesNo

Congestion or runny nose:
YesNo

Nausea or vomiting:
YesNo

Diarrhea:
YesNo

Student has sought medical care for COVID-19:
YesNo

Student has tested positive for COVID-19:
YesNo