Notification to resume attendance to School/Nursery/Childcare Center
Submission to:

School / Nursery / Childcare Center

School Grade:

Class:

Child / Student Name:※ Request to the member medical institution of Adachi City Medical Association
If patient is diagnosed with influenza, please cooperate to fill in the bolded frame (treated free of document fee).
※ If a medical institution you are treated is not a member of the Adachi Medical Association, a document fee may
be charged. In such case, parent /guardian is requested to fill in the bolded frame.

Influenza TypeA type・ B type

・ Unknown

Name of medical institution where influenza
was diagnosed.
Date when you went to doctor

Year:

Month:Day:(Day of week:)

Date of onset (fever)Year:

Month:Day(Day of week:)

Day 0Days sinceonset(Date ofonset）

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8／／／／／／／／／

Month/DayMax. bodytemperatureof the day
Day of thedecline of fever(put mark ○)Check the following reference "Criteria for the Period of Suspension of Attendance" , and If you meet the criteria,
put the check ☑ on the box below.

※□ Five days have passed since the onset of symptoms.
□ 2 days (3 days for infants) have passed after the decline of fever.
Since the above two criteria are met and in a condition that there are no obstacles to group life, my child will
resume school attendance from; Year:
Month:Day：.
Name of Parent/Guardian（signature of yourself）:【Reference】Criteria for the Period of Suspension of Attendance

Preschool Facilities

School・Childcare Ctr

Until 5 days have passed after the onset of symptoms and 2 days (3 days for infants) have passed after thedecline of fever.
Attendance is suspended on the day of the shaded area.
Day 0

Day 1

Day 2

Day 3
Day 2 after
decline offever

Day 4e.g.
1

Fever

Decline offever

Day 1 after
decline of
fever

e.g.
2

Fever

Fever

Fever

Decline offever

Day 1 after
decline of
fever

e.g.
3

Fever

Fever

Fever

Fever

Decline of
fever

Day 0

Day 1

Day 2

Day 3

Day 4

Day 2 after
decline offever

Day 3 after
decline offever
Day 1 after
decline of
fever

e.g.
1

Fever

Decline offever

Day 1 after
decline of
fever

e.g.
2

Fever

Fever

Fever

Decline of
fever

e.g.
3Fever

Fever

Fever

Fever

Decline of
fever

Day 5

Day 6

Day 7

Day 2 after
decline offever
Day 1 after
decline offever

Possible toresumeschoolPossible toresumeschoolDay 2 after
decline of
fever

Day 8

Possible toresumeschool

Day 5

Day 6

Day 7

Day 8

Day 2 after
decline offever
Day 1 after
decline offever

Possible toresumenursery
Day 3 after
decline offever
Day 2 after
decline offever

Possible toresumenursery
Day 3 after
decline offever

Possible toresumenursery

Preschool facilities: Kindergarten / Accredited Kodomoen / Approved Nursery School /Small Scale Childcare Service/Certified
Nursery School / Home-like Childcare※If respiratory symptoms (cough, runny nose, etc.) persist after the decline of fever, please see your doctor
before going to school, nursery or childcare center.
Adachi City Board of Education has already discussed with Adachi City Medical Association(Operation started on January,2023).

Notification to resume attendance to School/Nursery/Childcare Center
Submission to: X X X X X X Elementary
School Grade: X

Class: X

EntrySample

School / Nursery / Childcare Center

Child / Student Name: X X X X X XX

※ Request to the member medical institution of Adachi City Medical Association
If patient is diagnosed with influenza, please cooperate to fill in the bolded frame (treated free of document fee).
※ If a medical institution you are treated is not a member of the Adachi Medical Association, a document fee may
be charged. In such case, parent /guardian is requested to fill in the bolded frame.

A typeInfluenza Type・ B type

・ Unknown
Place〇 in theName of medical institution where influenza
was diagnosed.

X X X X ClinicDate when you went to doctor

Year: 202X Month: 2Day: 1(Day of the week: Wed.)

Date of onset (fever)

Year: 202X Month: 2

Day: 1(Day of the week: Wed.)corresponding
type

Rubber type seal by the clinic is acceptable.

Day 0Days sinceonset
Month/Day(Date ofonset）

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

2／1

2／2

2／3

2／4

2／5

2／6

2／7

／／

38.6

37.9

37.8

36.5

36.2

36.4

36.5

○

○

Max. bodytemperatureof the day
Day of thedecline of fever(put mark ○)Eg.1

Check the following reference "Criteria
put the check ☑ on the box b.

※Eg.2 On ２/3, had a fever until going to bed, but
woke up with normal temp. in the morning on 2/4
and no fever thereafter.

Eg.2

Period of Suspension of Attendance" , and If you meet the criteria,

Note‼ circle only
on the day of fever
resolution (eitherEg.1 orSince the above two criteria are met and in a condition that there are no obstacles to group
life,Eg.2).
my child will

☑ Five days have passed since☑ 2 days (3 days for infants) haveEg.1 Child had a fever in the morning on 2/3,but declined to normal temp. in the afternoon.

resume school attendance from; Year: 202X

Month: 2

Name of Parent/Guardian（signature of yourself）:

XXXX

Day：7
XXX

【Reference】Criteria for the Period of Suspension of Attendance

Preschool Facilities

School・Childcare Ctr

Until 5 days have passed after the onset of symptoms and 2 days (3 days for infants) have passed after thedecline of fever.
Attendance is suspended on the day of the shaded area.
Day 0Day 1

Day 2Day 3
Day 2 after
decline offever

Day 4e.g.
1FeverDecline offever

Day 1 after
decline offevere.g.
2Fever

Fever

Fever

Decline offever

Day 1 after
decline of
fever

e.g.
3

Fever

Fever

Fever

Fever

Decline of
fever

Day 0

Day 1

Day 2

Day 3

Day 4e.g.
1

Fever

Decline offever

Day 1 after
decline offever

Day 2 after
decline of
fever

e.g.
2

Fever

Fever

Fever

Decline offever

Day 3 after
decline offever
Day 1 after
decline of
fever

e.g.
3

Fever

Fever

Fever

Fever

Decline of
fever

Day 5

Day 6

Day 7

Day 2 after
decline offever
Day 1 after
decline offever

Possible toresumeschoolPossible toresume
schoolDay 2 after
decline of
fever

Day 8

Possible toresumeschoolDay 5Day 6Day 7Day 8

Day 2 after
decline offever
Day 1 after
decline offever

Possible toresumenursery
Day 3 after
decline offever
Day 2 after
decline offever

Possible toresumenursery
Day 3 after
decline offever

Possible toresumenursery

Preschool facilities: Kindergarten / Accredited Kodomoen / Approved Nursery School /Small Scale Childcare Service/Certified
Nursery School / Home-like Childcare※If respiratory symptoms (cough, runny nose, etc.) persist after the decline of fever, please see your doctor
before going to school, nursery or childcare center.
Adachi City Board of Education has already discussed with Adachi City Medical Association (Operation started on January, 2023).