RETURN TO SCHOOL OR CHILD CARE NOTE

[Practice name]
[Address]
[Phone]

Date: [Date you write the note]
To: [School or child-care program, and the nurse, principal, or director, if known]

Child: [Child's full name]
Date of birth: [Date]
Kept home since: [Date the child was sent home or stayed home]

ASSESSMENT
I assessed [child's name] [in person, by video, or by phone] on [date of the visit], with [parent or guardian's name].
Illness: [Name it only if the parent or guardian agrees; otherwise write: the illness for which the child was kept home]

RETURN RULE
Rule: [The exclusion rule the school, program, or health department uses for this illness, e.g. 24 hours of antibiotics and no fever, or all spots crusted]
How it is met: [What you found or confirmed, with dates and times, e.g. first antibiotic dose on date at time, or all lesions crusted on exam today]
Still to happen before return: [Nothing, or what the parent or guardian checks first, e.g. no fever on the morning of return without fever-reducing medicine]

RETURN
May return to [school, child care, or both] on: [Date]
Limits: [None, or what the child should not do and until when, e.g. keep sores on exposed skin covered]
Medicine during the day: [None, or what the school or program needs to give, on its own medication form]

This note covers only the illness above, as I assessed it on the date given.

[Parent or guardian's name] asked for this note and agreed to what it shares.

[Your name, credentials]
[License or registration number]
[Signature]

To verify this note: [Practice phone]