Appendix J: Exclusion Form
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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: _________