Daily Self-Assessment Agreement – Daily Self Assessment Agreement ENG SPAN TRANS

This agreement must be completed by all families. The form is fillable and can be saved to your computer and emailed to your school nurse or registrar (secretary). It may also be printed, signed, and returned to the school. Click here for the agreement.

List of School Nurses click here

List of school registrars:

Chamberlain – shull@goshenschools.org
Chandler – anisley@goshenschools.org
Model – acox@goshenschools.org
Parkside – sbarraza@goshenschools.org
Prairie View – shtaylor@goshenschools.org
Waterford – jrohn@goshenschools.org
West Goshen – tunrue@goshenschools.org
GMS/GHS – send to Nurse

Daily Self-Assessment

Please do this at home before leaving for school.

Does your student have:

  1. Loss of smell or taste, or a change in taste
  2. Headache
  3. Fever (or fever-like symptoms: alternating chills and sweating)
  4. Cough
  5. Trouble breathing or shortness of breath
  6. Chills or repeated shaking with chills
  7. Muscle aches
  8. Sore throat
  9. Congestion or runny nose
  10. Nausea or vomiting
  11. Diarrhea

If your student has any of the above symptoms without being otherwise explained – STAY AT HOME.

Please contact the school and indicate your child has COVID-19 symptoms and will not be in.  Contact the school nurse regarding when your child may return.

Positive COVID-19

If a student tested Positive for COVID-19, they cannot return until:

  1. The student is symptom-free including fever free for 24 hours without the use of fever-reducing medications


  1. 10 days have passed since student’s symptoms first appeared

Exposure to COVID-19

  1. Has the student been within 6 feet- for more than 15 minutes of someone that is scheduled to be tested, has been tested, or tested positive for COVID-19?
  2. Has the student been in direct contact with the secretions (i.e. fluids from a sneeze or cough) of someone that is scheduled to be tested, has been tested, or tested positive for COVID-19 in the past 14 days?

If the answer is yes to either question, please stay home. If your student has been exposed to someone who had a positive test, please contact your school nurse.


Have you traveled to any country, state, or location where COVID-19 has sustained widespread community transmission in the past 14 days?

If the answer is yes or you do not know if COVID -19 is widespread, please contact Susan Stiffney (574 533-8631) or Wendy Swallow (574 533-8651).
If you have any further questions or concerns, please contact your school nurse.