Return-to-school and illness exclusion: the complete parent chart
Every district publishes a version of this and almost every version is a scan of a scan. This one states, for each condition, the criterion for sending a child home and the separate criterion for letting them back — because those are different tests, and the second one is what parents are actually searching for at half past six in the morning.
| Situation | Send home? | Return when | Provider note commonly asked |
|---|---|---|---|
| Fever at or above your district threshold | Yes | 24 hours fever-free without fever-reducing medication | No |
| Vomiting | Yes | Typically 24–48 hours after the last episode, per local rule | No |
| Diarrhoea | Yes | Stools formed and contained; longer for confirmed enteric pathogens | For confirmed pathogens |
| Cough, no fever, child well | No | No exclusion | No |
| Runny nose, no fever | No | No exclusion | No |
| Sore throat, no fever, undiagnosed | No | No exclusion | No |
| Strep throat, diagnosed | Yes | After the antibiotic period your state specifies, and fever-free | Some districts |
| Scarlet fever | Yes | As for strep — the rash itself is not the criterion | Some districts |
| Influenza | Yes | 24 hours fever-free without medication and improving | No |
| COVID-19, positive | Yes | Symptoms improving and 24 hours fever-free without medication | No |
| RSV | If febrile or unwell | Fever-free 24 hours and well enough to participate | No |
| Norovirus / stomach bug | Yes | Commonly 48 hours symptom-free; some settings require 72 | No |
| Hand, foot and mouth | Not routinely | Fever-free, able to control secretions; blisters need not be healed | No |
| Chickenpox | Yes | All lesions crusted, or no new lesions for 24 hours | Sometimes |
| Measles | Yes | Four days after rash onset, per health department | Health dept clearance |
| Mumps | Yes | Typically 5 days after parotitis onset | Sometimes |
| Pertussis | Yes | After the prescribed antibiotic course period | Commonly |
| Conjunctivitis, no fever | Not routinely | No exclusion under current guidance | No |
| Impetigo | Until treatment starts | 24 hours of treatment and lesions covered | No |
| Ringworm of the body | No | Treatment started; lesion covered for contact sport | No |
| Ringworm of the scalp | Local rule | Treatment started | Sometimes |
| Scabies | Yes | After the first treatment is completed | Sometimes |
| Head lice | Not under current guidance | No exclusion recommended | No |
| Fifth disease | No — contagious period has passed | No exclusion once the rash appears | No |
| MRSA skin infection | If draining and uncoverable | Lesion covered and drainage contained | Sometimes |
| Undiagnosed rash with fever | Yes | Evaluated, or rash resolved and fever-free 24 hours | Commonly |
| Undiagnosed rash, no fever, child well | No | No exclusion | No |
| Head injury during the day | Per protocol | Per concussion protocol — not a nurse decision alone | Yes |
| Toothache or dental pain | No | Not an exclusion; refer | No |
| Molluscum contagiosum | No | No exclusion; cover for contact sport | No |
| Chronic condition flare (asthma, migraine) | Per care plan | Per the plan on file | Plan, not a note |
| Too unwell to take part, no specific finding | Yes | Well enough to participate in the school day | No |
Written to be adapted, not adopted. Several rows are set by your state health code or local health jurisdiction and genuinely vary — the vomiting and diarrhoea intervals, the strep antibiotic period, and the enteric-pathogen clearance rules in particular. Confirm each against your own state guidance and district policy before this goes into a handbook.
Twenty-four hours fever-free, counted properly
This is the single most misunderstood rule in school health, and the misunderstanding is entirely the fault of how districts write it.
The rule is: twenty-four hours with no fever, without having taken anything that lowers a fever. Both halves matter.
- What counts as fever. Districts typically set the threshold at 100.0°F or 100.4°F. Yours is one of them; find out which and put it in the letter as a number, because "a fever" means different things to different families and to different thermometers.
- What counts as a fever reducer. Acetaminophen and ibuprofen, under any brand name, and any combination cold product containing them. Families routinely give a combination medicine at bedtime without registering it as a fever reducer.
- When the clock starts. At the last elevated reading, or at the point the last dose of fever reducer wore off — whichever is later.
Three worked examples, which are what actually stop the arguments:
- Tuesday 2pm, 101.3°F, no medication given. Wednesday, no fever. The clock started Tuesday 2pm and runs to Wednesday 2pm. Thursday morning is the return, not Wednesday.
- Monday 8pm, ibuprofen given, no fever afterwards. The clock does not start at 8pm. It starts when the dose has worn off, so Tuesday morning at the earliest, and the return is Wednesday.
- Fever gone Wednesday morning, child fine all day, low fever again Wednesday night. The clock restarts Wednesday night. This is the case families dispute most, and it is also the case where returning too early does the most damage.
Put those three examples in your handbook. They do more for compliance than another paragraph of policy.
Can you require a doctor's note?
This one is worth thinking about carefully, because it is the place where a well-intentioned policy quietly becomes an equity problem.
The legal position varies. Some states restrict what a school may require in order to readmit a student, and some address provider notes specifically in health or attendance code. Many say nothing, leaving it to district policy. Confirm your own.
The practical position is more consistent. A note requirement costs a family an appointment, a co-pay, and often a day of missed work, for a condition that a provider will confirm has resolved without doing anything about it. Families with a paediatrician on a portal produce the note in an afternoon; families using an urgent care clinic after a shift may not produce it at all, and the absence extends. The requirement therefore falls hardest on exactly the households whose children can least afford the extra days.
Where a note requirement is genuinely useful is narrow: conditions where a health-department clearance is part of the public-health process, conditions where the return decision needs clinical judgement rather than a rule a parent can apply, and head injury, where the return-to-learn decision is not the nurse's alone.
If you keep a note requirement, two mitigations are worth building in: accept a parent's written statement for ordinary illness, reserving the provider note for the narrow list; and make the health office able to accept a photograph of the note rather than the paper original.
The eight letters
1. Annual back-to-school policy letter. The chart, plus the fever rule with worked examples, plus the health office number. Send in August, and again in the first week of January — the second send is the one that reduces February arguments.
2. Mid-year reminder. Short, seasonal, sent at the start of respiratory season. A reminder from the health office as we head into the winter: the rule for coming back after a fever is 24 hours with no fever and no fever-reducing medicine. If your child is well enough to take part in the school day, they are well enough to be here — a cough alone is not a reason to keep a child home.
3. Individual sent-home letter. What was found, what the return criterion is, the earliest return date stated as an actual date, and a phone number. Stating the date rather than the rule removes every subsequent phone call.
4. Health-linked absence letter. For a student whose absence total is climbing on genuine illness. This must not read like a truancy notice — it should offer help, mention the possibility of a health plan, and be co-ordinated with attendance so the family does not get both letters in the same week. See excessive excused absences.
5. Policy-change letter. When the chart changes, say what changed, why, and from when. Never quietly reissue an updated chart.
6. Staff version. Same chart, plus who decides, plus what to do before the nurse arrives, plus the instruction not to diagnose in the classroom.
7. Pre-K version. Childcare licensing rules are frequently stricter than K–12 health code for the same condition, which produces the most common complaint in any district running both: the same illness, two different answers, in two rooms of one building. Say so explicitly rather than letting families discover it.
8. Letter to a family repeatedly sending an unwell child in. The hardest one. Almost always a work or childcare problem rather than a defiance problem, so lead with that: I know that keeping [STUDENT FIRST NAME] home is not simple, and I would rather help you work out an option than keep sending them back. Can we talk?
The fridge version, and how to send it
The version families keep is not the chart. It is ten lines, in plain language, on one page, in English and Spanish.
KEEP AT HOME: fever of [THRESHOLD] or higher · vomiting · diarrhoea · a rash with a fever that has not been checked · too unwell to take part in the day.
COME TO SCHOOL: a cough with no fever · a runny nose with no fever · a sore throat with no fever · pink eye with no fever · head lice · a rash with no fever if your child is well.
COMING BACK: after a fever, 24 hours with no fever and no fever medicine. After vomiting, [YOUR INTERVAL] with no vomiting. If you are not sure, call [PHONE] — we would rather answer the question than have you guess.
MANTENGA EN CASA: fiebre de [LÍMITE] o más · vómitos · diarrea · salpullido con fiebre sin revisar · demasiado enfermo para participar en el día escolar.
PUEDE VENIR A LA ESCUELA: tos sin fiebre · catarro sin fiebre · dolor de garganta sin fiebre · conjuntivitis sin fiebre · piojos · salpullido sin fiebre si el niño se siente bien.
PARA REGRESAR: después de una fiebre, 24 horas sin fiebre y sin medicamento para la fiebre. Después de vómitos, [INTERVALO] sin vomitar. Si tiene dudas, llame al [TELÉFONO]; preferimos contestar su pregunta.
Sending it as text, not as an image. The fridge sheet works on paper. As a message it should be sent as plain text, split across two or three SMS sends, not as a picture of a page — images do not reach every device the same way, they cannot be read by a screen reader, and they cannot be translated. Kastr carries no attachments at all, which forces the right behaviour here: the content goes in the body, or it goes on paper. The composer's cost preview will show you what a three-part text to every household actually costs before you send it, which is a number worth seeing.
Questions people actually ask
Can a school require a doctor's note before a child returns?
Sometimes, and the answer depends on your state and your district policy — some states restrict what a school may require for readmission. Even where it is permitted, weigh what it costs: an appointment, a co-pay and often a lost shift, falling hardest on households that can least absorb it, to confirm something a parent can already observe. Reserve it for conditions where clinical judgement or a health-department clearance is genuinely needed.
How exactly do I count 24 hours fever-free?
From the last elevated temperature, or from the point the last dose of acetaminophen or ibuprofen wore off, whichever is later. A fever that returns restarts the clock. The most common error is starting the count from the evening a fever reducer was given, which produces a return roughly twelve hours too early — usually into the most contagious part of the illness.
Can my child come to school with a cough but no fever?
Yes. A cough alone, with no fever and a child who is well enough to take part in the day, is not a reason to stay home — and if it were, a large share of children would be absent from November to March. What changes the answer is fever, difficulty breathing, or a child too unwell to participate.
Does the school decide when my child returns, or does the doctor?
Both, in different lanes. The school sets and applies the exclusion rules, which are the same for every student and come from state health guidance and district policy. Your provider decides what treatment your child needs and, for a few conditions, whether they are clear to return. Where a provider and a district rule genuinely conflict, call the health office — that is a conversation, not a form.
What if I cannot miss work to keep my child home?
Call the health office and say so. It is one of the most common realities in a school community and nurses hear it constantly. There is often something available — a later start, a different family contact on record, a referral to a local resource — and even where there is not, a nurse who knows the situation makes better decisions about your child than one who is guessing.
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