3.6: Appendix E - Exclusion Form
selected template will load here
This action is not available.
Child’s Name:____________________________________ Date:__________________________
Today your child was observed to have the following signs or symptoms of illness:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Based on our exclusion policy, your child is being excluded from care: yes no
If excluded, your child can return when:
Parent/guardian: ________________________________ Date: ____________ Time: _________