(School Name) Annex 11
Declaration form on health status of students
Name of Student： ________________ Student Reference Number ： _____________ Sex ： M ／ F
Please complete the below form and return to the school (Please put a “” in the appropriate box).
Part A – Whether your child has symptoms of COVID-19
*My child has symptoms of COVID-19, such as having a fever (body temperature at 38oC or above), symptoms of acute respiratory tract infection, or sudden loss of sense of taste or smell, etc.
My child does NOT have any symptoms of COVID-19 or acute respiratory tract infection.
Part B – Whether your child is undergoing mandatory quarantine
*My child is undergoing mandatory quarantine (including StayHomeSafe Scheme or home isolation) today, i.e. the day of the Test.
My child is NOT undergoing mandatory quarantine (including StayHomeSafe Scheme or home isolation) today, i.e. the day of the Test.
Part C – Whether your child has done the COVID-19 rapid antigen test (RAT)
*My child has NOT done the RAT today, i.e. the day of the Test.
*The RAT result of my child was positive today, i.e. the day of the Test.
My child has done the RAT today, i.e. the day of the Test, and the result was negative.
*If you tick this box, you should not let your child go to school to take the Test.
Name of Parent/Guardian (in Block Letter) : ___________________________
Signature of Parent/Guardian : ____________________________________
Date: ________________________
