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last updated: 2026-03-06 by BA
file_name: 2020-09-01_School Testing_UnitedHealth Group - Safe and Strategic Return to School.md
file_date: 2020-09-01
title: UnitedHealth Group - Safe and Strategic Return to School (Sept 2020)
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tags: school testing, uhg
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summary_short: UnitedHealth Group’s Safe and Strategic Return to School (September 2020) compiles COVID-19-era recommendations for reopening and keeping K–12 schools open, including a community transmission “action level” framework tied to in-person/hybrid/remote models. It lays out practical operational guidance on ventilation, distancing, cleaning, transportation, symptom screening, testing (including pooling), communication, and outbreak response. A “Safe Health Compact” summarizes shared responsibilities for schools and families to support compliance and continuity of instruction.


CONTENT

UNITEDHEALTH GROUP

***INTERNAL TITLE:*** Safe and Strategic Return to School
September 2020

With over 150 million people reliant on UnitedHealth Group (UHG) services, we are committed to using our entire ecosystem to improve the health of the people we serve. The following information is a compendium of sourced recommendations based on local and national guidelines. UHG offers this guidance covering the following topics to support safe and strategic in-person education:
1. **Know the prevalence and risk for your community**
   a. Data for the school's service area should confirm flattening curves (fewer new cases)
   b. Confirm appropriate healthcare system capacity
2. **Support your school system**
   a. Prepare your buildings:
      i. Evaluate traffic flow through common areas to avoid crowding
      ii. Ensure adequate ventilation
      iii. Reset classrooms to create space for learning with social distancing guidelines
   b. Evaluate ancillary processes, such as transportation and meal delivery, to ensure safe delivery of these services
   c. Ensure frequent and open communication with stakeholders, including staff, students, families, and community members
3. **Support your staff, students, and parents**
   a. Develop a social contract to instill mutual trust and accountability
   b. Educate staff on symptoms and risk factors, ensuring adequate protection for high-risk staff
   c. Supply staff with personal protective equipment (PPE)
   d. Supply students with masks
   e. Implement a symptom tracking program, which could include temperature tracking
   f. Consider surveillance testing (if available)
   g. Provide mental health supports for all staff and ensure that robust mental health supports are available for students and families
   h. Educate families on symptoms and risk factors, ensuring that alternative models of education are available for high-risk students
   i. Create protocols for special education students
4. **Take steps to keep your classrooms open**
   a. Create a decision-making process that incorporates local guidance and the Community Action Level for Schools
   b. Evaluate hybrid or wave models to return to the classroom
   c. Review all extracurricular activities and modify for safety
   d. Develop a comprehensive plan to support staff and students if an outbreak occurs

## Introduction
As school leaders prepare for the 2020–2021 academic year, schools will need effective science- and data-driven strategies to form plans to reopen and remain open which balance quality of education with the health and safety of students, teachers, and staff.

Schools are essential to successful communities and long-term disruptions to school can be catastrophic for children. For example, Hurricane Katrina, which closed New Orleans schools for several months in 2005 and displaced thousands of students, had significant consequences for children as they returned to New Orleans. School leaders reported that students returned to school more than two years below grade level, and it took multiple years of individualized attention to resolve learning losses. In 2015, Louisiana topped the nation with the highest number of opportunity youth—ages 16 to 24—who are neither working nor in school and who would have been elementary students when Katrina hit. The COVID-19 pandemic's interruption of education may have a lifetime impact on an entire generation of children. Care must be taken to lessen this impact as much as possible.

However, schools cannot remain open at any cost. The safety of students and staff must be prioritized. A Gallup survey from July 2020 found that 57% of teachers are very concerned about being exposed to coronavirus in the workplace compared to 21% of all other US workers, and 24% of teachers are at heightened risk of COVID-19 infection. Additionally, according to the Kaiser Family Foundation, a majority of mothers worry that their child (77%) or another family member (77%) will get sick if their child returns to school in person and 73% are concerned that schools will be unable to comply with public health recommendations. It is apparent that clear communication strategies paired with accommodations for high-risk individuals are critical for ensuring success and reducing anxiety in order to keep children in the classroom.

With over 150 million people reliant on UnitedHealth Group (UHG) services, we are committed to using our entire ecosystem to improve the health for the people we serve. Health is comprised of the physical, mental, social, financial, and spiritual wellbeing of a person or population, and—according to the World Health Organization—the traditional healthcare system only contributes about 10% to overall health, with the balance being composed of social, environmental, behavioral, and genetic factors. As such, it is important to address all of these aspects of a person's community in order to reduce the risk of future illness and increasing the chance to be a productive member of society. With this aim in mind, UHG offers this guidance covering the following topics to support safe and strategic in-person education:

1. Know the prevalence and risk for your community
2. Support your school system: buildings, classrooms, and processes
3. Support your staff, students, and parents: social contract, education, communication, and protocols
4. Take steps to keep your classrooms open: establishing routines and auditing performance

## 1. Know the Prevalence and Risk for Your Community
Keeping staff and students in schools starts with understanding the infection rate within your community. Stabilizing or declining case counts ("flattening the curve"), testing and contact tracing availability, hospital capacity, and PPE availability, as well as state and local guidelines, will determine whether a community is able to safely continue in-person learning.

UHG's Community Alert Level—Schools (Table #1) provides guidance for levels of community transmission and the appropriate actions that should be taken at each level. Monitoring school and community health department data are also important for identifying potential spikes in infectivity and taking action to anticipate and manage outbreaks.

### Table #1: Community Action Level—Schools
| Sum of New Cases in District Area (last 14 days) | Procedure | People | Symptom Checking | Temperature Testing | Other Protocol (each level is additive) |
|--------------------------------------------------|-----------|--------|-------------------|---------------------|----------------------------------------|
| Level 1 <10/100,000 | In-Person Classes for All Students | Students | Daily | Not required | • Hygiene protocols in place<br>• No groups of more than 50 |
| Level 1 <10/100,000 | In-Person Classes for All Students | Faculty & staff | Daily | Not required | • Hygiene protocols in place<br>• No groups of more than 50 |
| Level 1 <10/100,000 | In-Person Classes for All Students | Delivery/contractors/etc. | Daily | Not required | • Hygiene protocols in place<br>• No groups of more than 50 |
| Level 1 <10/100,000 | In-Person Classes for All Students | Visitors | Day of visit | Not required | • Hygiene protocols in place<br>• No groups of more than 50 |
| Level 2 10-199/100,000 | In-Person Classes for Most Students | Students | Daily, 7 days prior | Not required | • High-risk stay home<br>• Enhanced cleaning protocols in place<br>• Mandatory 6' physical distancing or strict mask use when distancing not possible due to behavior or physical space |
| Level 2 10-199/100,000 | In-Person Classes for Most Students | Faculty & staff | Daily, 7 days prior | Not required | • High-risk stay home<br>• Enhanced cleaning protocols in place<br>• Mandatory 6' physical distancing or strict mask use when distancing not possible due to behavior or physical space |
| Level 2 10-199/100,000 | In-Person Classes for Most Students | Delivery/contractors/etc. | Daily | Not required | • High-risk stay home<br>• Enhanced cleaning protocols in place<br>• Mandatory 6' physical distancing or strict mask use when distancing not possible due to behavior or physical space |
| Level 2 10-199/100,000 | In-Person Classes for Most Students | Visitors | Daily, 7 days prior | Not required | • High-risk stay home<br>• Enhanced cleaning protocols in place<br>• Mandatory 6' physical distancing or strict mask use when distancing not possible due to behavior or physical space |
| Level 3 200-399/100,000 | Hybrid Classes | Students | Daily, 12 days prior | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 3 days in and 2 days out (3-2) model<br>• Restrictions on common areas<br>• Essential visitors only |
| Level 3 200-399/100,000 | Hybrid Classes | Faculty & staff | Daily, 12 days prior | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 3 days in and 2 days out (3-2) model<br>• Restrictions on common areas<br>• Essential visitors only |
| Level 3 200-399/100,000 | Hybrid Classes | Delivery/contractors/etc. | Daily | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 3 days in and 2 days out (3-2) model<br>• Restrictions on common areas<br>• Essential visitors only |
| Level 3 200-399/100,000 | Hybrid Classes | Visitors | Daily, 12 days prior | Day of visit | • High-risk stay home<br>• Hybrid learning using groups rotating 3 days in and 2 days out (3-2) model<br>• Restrictions on common areas<br>• Essential visitors only |
| Level 4 400-599/100,000 | Hybrid Classes | Students | Daily, 14 days prior | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 4 days in 10 days out (10-4) model<br>• No in-person group extracurricular activities |
| Level 4 400-599/100,000 | Hybrid Classes | Faculty & staff | Daily, 14 days prior | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 4 days in 10 days out (10-4) model<br>• No in-person group extracurricular activities |
| Level 4 400-599/100,000 | Hybrid Classes | Delivery/contractors/etc. | Daily | Daily | • High-risk stay home<br>• Hybrid learning using groups rotating 4 days in 10 days out (10-4) model<br>• No in-person group extracurricular activities |
| Level 4 400-599/100,000 | Hybrid Classes | Visitors | No visitors | No visitors | • High-risk stay home<br>• Hybrid learning using groups rotating 4 days in 10 days out (10-4) model<br>• No in-person group extracurricular activities |
| Level 5 >=600/100,000 | Distance Learning for All Students | Students | Daily | Daily | • Close facility except for essential workers and essential services |
| Level 5 >=600/100,000 | Distance Learning for All Students | Faculty & staff | Daily | Daily | • Close facility except for essential workers and essential services |
| Level 5 >=600/100,000 | Distance Learning for All Students | Delivery/contractors/etc. | Daily | Daily | • Close facility except for essential workers and essential services |
| Level 5 >=600/100,000 | Distance Learning for All Students | Visitors | No visitors | No visitors | • Close facility except for essential workers and essential services |
||

### Declining Case Counts
Stabilizing the rate of infections is important for preventing ongoing virus transmission and stabilized or declining case counts are required for safely staying in the classroom. School leaders should look at their community's 14-day average case count per hundred thousand population as the primary indicator of viral transmission in the community. This metric is calculated as follows:
1. Divide the population of the school's service area by 100,000
2. Add all new cases in the last 14 days in the service area
3. Divide the total new cases (2) by the output of the first division (1)

This metric could be analyzed at the zip code level or the county level depending on the district area and the data available from the local health department. This metric provides guidance as to whether there are low enough levels of viral transmission to allow for in-person instruction.

#### Testing and Contact Tracing Capacity
Adequate regional capacity for rapid diagnostic testing is crucial for keeping active infections at a safe enough level for remaining in school. This means available testing for (1) hospitalized patients, (2) healthcare workers, (3) all other essential workers in public-facing roles, (4) anyone seeking outpatient care for symptoms, and (5) close contacts of those with confirmed diagnoses. Modeling shows that in populations with adequate physical distancing measures, contact tracing can act synergistically with other containment measures as part of a back-to-work strategy. State health departments may have the most up-to-date information about regional testing and contact tracing.

### Healthcare System Capacity
Regional hospital capacity should be adequate to treat everyone requiring hospitalization at the standard of care, as opposed to a crisis standard of care, as defined by the Institute of Medicine. This should include adequate ICU bed availability and adequate PPE for the healthcare workforce.

Adequate ICU bed availability is defined, according to the Society of Critical Care Medicine, as capacity to expand to 5–7 beds per 10,000 adults, allowing for regional variation and including adequate staffing (with emergency plans in place to increase that number to 30 beds per 10,000 adults in case of a surge). The Centers for Disease Control (CDC) publishes a dashboard on national and state-level hospital bed availability.

Adequate PPE, as recommended by the CDC, includes gloves, N95 respirators, face masks, shields, and isolation gowns for all healthcare providers, along with face masks for patients with confirmed or suspected cases. Many state health departments have the most up-to-date information about regional PPE supply chains.

#### International Guidance
Some countries have returned to in-person education, and the outcomes of these initial openings can be used to inform the development of plans for maintaining in-person education in the US. ISC Research, a provider of English-medium K-12 international school data, is tracking back-to-school plans in the US and internationally and may be a useful source of updates. In addition, the European Union is tracking the responses of its member states for opening schools.

#### State and Local Guidelines

School leadership should evaluate their state and local guidelines for additional guidance, if available.

## 2. Support Your School System
Building and classroom preparation are required. Adequate space to accommodate physical distancing, robust ventilation systems, modified transportation capacity, and frequent cleaning are critical for safely remaining in the classroom.

### Building Capacity to Support Physical Distancing
Classrooms need to be modified to ensure that students and staff have adequate space for physical distancing. Desks and workstations should be spaced or blocked to provide six feet of distance between people working. If workstations are to be occupied by different individuals throughout the school day, the workstations should be fully disinfected between uses. Plexiglass dividers can be used in areas where distancing may not be achievable. Close or modify common areas, gymnasiums, and cafeterias.

Students should avoid unnecessary travel and exposure to other students. Consider having teachers or educators move between classrooms for different subjects whenever possible instead of the traditional movement of students between classrooms. Keeping students in classes or pods can limit transmission if a positive case occurs in the school.

Outside the classroom, consider adding signage to limit the number of people in elevators or other tight spaces. Encourage one-way traffic flow in hallways and stairwells. Signage and floor stickers can remind students and staff of distancing requirements. If possible, modify entrances, cafeterias, and other common spaces to reduce or eliminate crowding. Minimize touchpoints, such as using automated door openings or modifying door handles to allow for pushing doors open.

School leaders should consider modifying start and end times to allow for staggered arrivals to reduce crowding at the beginning and end of each school day as well as during breaks, if transportation and other policies can accommodate.

Conduct routine audits to evaluate the effectiveness of current physical distancing practices. These audits will use current CDC and OSHA guidelines for ongoing best practices. Physical distancing audits could consider how the organization has altered or should continue to alter its personnel policies in order to maintain the lowest risk of virus transmission. These audits would review policies regarding procedures for reintroducing employees into traditional school settings and allowing them to safely remain in these settings, as well as preparedness measures in the event of employees being exposed to COVID-19. Audits of which policies are working may result in revisions to school policy in order to follow best practices, such as dismissal and physical distancing practices.

### Residential Schools
Residential schools should consider additional modifications to living areas. For common areas (shared kitchens, dining rooms, laundry rooms, bathrooms, activity rooms, exercise rooms, etc.), restrict access to a limited number of people at one time and reconfigure space to allow for adequate physical distancing. Shared kitchens and bathrooms merit particularly frequent and careful cleaning.

Residential schools should also provide isolation and quarantine areas for residents who contract or are exposed to COVID-19. If on-campus housing is not feasible, consider off-campus locations for isolation and quarantine. Similar accommodations are recommended for students who live off campus. Any isolation and quarantine facilities must be physically separated from residential spaces and must bear proper signage indicating that they are restricted areas but should not indicate their purpose due to concerns of stigma and FERPA/HIPAA violations. Rooms for isolation and quarantine should have private bathroom facilities and be provided with a thermometer, sanitizing wipes, tissues, soap, hand sanitizer, and toiletries.

### Ventilation
Adequate ventilation is key for reducing aerosol transmission. Consider reviewing the ventilation systems in school buildings in consultation with HVAC professionals to ensure best practices whenever possible, with considerations for local weather and air quality. These can include increasing the percentage of outdoor air circulating in the building by both opening windows (if local air quality permits) and opening minimum outdoor air dampers as high as 100% if systems permit. Increase central air filtration to the highest filtration available and run filtration systems 24/7 whenever possible to ensure continuous air flow. Ventilation is also important when cleaning and disinfection are taking place.

School leaders should explore the feasibility of using other community spaces or outdoor spaces for classrooms, both to increase ventilation and to achieve physical distancing. In Italy, for example, schools are using closed movie theaters, church halls, and tented outdoor space for additional classroom space.

### Hygiene
Signage and handwashing stations can help encourage students and staff to regularly wash their hands and reduce crowding at existing sinks or bathrooms. Use automated soap dispensers whenever possible to reduce touchpoints. The CDC recommends washing with soap and water because it is more effective than hand sanitizers at removing germs and chemicals, especially when hands are dirty. When soap and water are not available, students and staff should have access to hand sanitizer containing at least 60% alcohol. To prevent poisonings from the ingestion of hand sanitizer, place immovable dispensers in highly visible locations where use can be monitored. To preserve skin health and prevent irritation that can accompany frequent hand washing and the use of hand sanitizers and other disinfectants, consider making hypoallergenic hand lotion available. Disinfecting wipes should also be accessible for students and staff to clean desks and keyboards.

### Cleaning Protocols
Cleaning services should regularly disinfect all classrooms, common areas, and workspaces. Consider providing cleaning staff with training or educational materials on the safe handling of cleaning products, adequate protective equipment, and clear protocols for preventing overexposure to chemicals.

The coronavirus has been found to live on glass, metal, ceramic, or paper surfaces for five days, wood for four days, plastics or stainless steel for two to three days, cardboard for one day, copper for four hours, and aluminum for two to eight hours.

Schools should follow research-backed disinfecting practices as closely as possible. The CDC has issued interim recommendations for cleaning and disinfecting community facilities. For disinfecting hard, non-porous surfaces, most common EPA-registered household disinfectants are effective. Household bleach will be effective against coronaviruses when properly diluted (1/3 cup per gallon of water). For soft, porous surfaces such as carpeted floors or rugs, clean with appropriate cleaners indicated for use on those surfaces. If items can be laundered, launder using the warmest appropriate water setting for the items and then dry completely. For electronics, follow the manufacturer's instructions for all cleaning and disinfection and consider use of wipeable covers for electronics. If no manufacturer guidance is available, use alcohol-based wipes or sprays that contain at least 70% alcohol. Dry surfaces thoroughly. Remind employees to adhere to the recommended "wet time" (time the surface must remain wet with the cleaning product in order to kill bacteria, virus, and parasites) for the product used.

Consider providing staff and students with disinfecting wipes to use on their individual workstation to reinforce the importance of cleaning and hygiene.

#### Cleaning after Exposure
When persons suspected or confirmed to have COVID-19 have been in a school facility, that site should be decontaminated. CDC guidelines for cleaning and disinfection of facilities where there have been suspected or confirmed cases recommend closing off areas visited by the ill persons and, if possible, opening outside doors and windows, using ventilating fans to increase air circulation in the area, and then waiting 24 hours or as long as practical before cleaning and disinfecting. Cleaning staff should then clean and disinfect all areas used by the infected persons, focusing on frequently touched surfaces.

Consider using foggers or misting equipment from a professional decontamination service. This would allow a site to be closed for a period of time so the infectious droplets could settle and then be effectively cleaned by standard protocols, or to introduce sufficient ventilation to effectively disperse the infected particles.

Conduct internal sanitation audits regularly to document what is being done correctly or incorrectly and identify areas where improvement is required. Consider noting in any routine sanitation audits any surfaces in the building most likely to harbor germs, including chairs, coffee stations, desks, door handles, light switches, reception areas, tables, elevator buttons, etc., and creating a plan to address any issues identified in the audits.

### Transportation
Evaluate school transportation options to determine what modes of transportation can maintain optimal physical distancing. Buses can be modified to maintain social distancing guidelines. For example, a 77-passenger bus can be modified to hold 13 students at six feet apart, or 26 students at five feet apart. Siblings can sit together, which can increase available capacity. Use signage or tape to mark where students can and cannot sit. Sequential seating should be encouraged, where students take the rear-most available seat. Seating charts can be used to support contact tracing efforts.

If a school district requires families to do symptom checking, parents should complete symptom tracking before they leave for the bus stop. Masks should be required for students while on the bus; extra masks should be available for students if they forget theirs at home. To protect bus drivers, plexiglass can be used as a barrier around the driver's seat. Bus drivers should also wear masks. Whenever possible, windows should be open to encourage air flow. Buses should be disinfected in between uses or as frequently as possible.

Shared transportation in smaller vehicles (such as carpooling or shuttles) should be avoided for both students and employees.

### Meals
Meals should be prepared following standard food safety guidelines. Whenever possible, meals should be delivered to classrooms and students should eat at their individual desk or workstation with sufficient physical distance rather than in a cafeteria setting to minimize exposure to large groups. Re-evaluate "open campus" high school policies that allow teaching staff and older students to leave campus for lunch based on community health data.

Given that food insecurity has increased and that students from lower-income families may have received one or two meals per day at school before distance learning began, schools should consider ways to make lunches available for students to pick up when they are not at school in person. Other than continuing to order from schools' usual food providers, food banks and other community organizations in many areas are partnering with school districts to provide meals to students.

### Communication Plan
Develop and implement an ongoing communication plan to provide training and health and safety information for students, parents, and staff. Consider developing and testing information-sharing systems for schools and parents/guardians so that COVID-19-related information can be communicated quickly and effectively. These information-sharing systems should include the following:
- Day-to-day reporting on disease surveillance (with two-way reporting between schools and parents/guardians)
- The ability to track the occurrence of symptoms
- Connection and access to local health officials

## 3. Support Your Staff, Students, and Parents
A Gallup survey from July 2020 found that 57% of teachers are very concerned about being exposed to coronavirus in the workplace compared to 21% of all other US workers, and 24% of teachers are at heightened risk of COVID-19 infection. Clear communication strategies, paired with accommodations for high risk individuals, are critical to ensure success in maintaining in-person education and reduce anxiety amongst staff. Inviting teachers and staff to participate in the planning process can build shared trust and ensure multiple perspectives are considered.

Students, parents or guardians, and families also need clear communication throughout the school year. Recent polling suggests that 59% of responding parents were not comfortable with returning to school in the fall, yet 66% of parents have concerns about how distance learning will impact their children's mental health. Families should be provided with transparent information throughout the process and be prepared in advance for changes to models throughout the year.

### Social Contract
Develop a social contract that lays out the school, staff, student, and parent/guardian commitment to health and safety. A social contract between administrators, staff, students, and families can build mutual trust, ground decision-making in shared values, and ensure that all perspectives are considered when determining when to return to the classroom. A social contract instills mutual trust and can drive compliance for all participants. The most successful social contracts rely on mutual trust between those involved, rather than formal attestation. People choose to abide by the commitments in a social contract when they believe their leaders demonstrate commitment to those values and see each participant fulfilling their duties as part of the contract.

Social contracts should consider behaviors both at school and outside of school. Viral transmission at large group gatherings are common and even heightened in certain circumstances that could occur outside of school (e.g., choir rehearsals, weddings, sporting events). Although these happen outside of the school day, students and parents need to consider how all their actions impact the school community.

Schools should also consider potential consequences for students who show poor adherence to the school's social contract, such as exclusion from participating in extracurricular activities or from attending school in person.

### Pandemic Education Materials
As part of the social contract, consider providing materials specific to faculty and staff on the school's plans and guidelines to create and maintain a safe and effective learning environment. Also provide age-appropriate educational materials to students and parents to explain the school's plans, guidelines, and expectations. Engage parents as early and as often as possible, both to provide updates and seek input. This includes training/education on updated school safety, hygiene policies, and resources (possibly leveraging CDC or WHO materials).

Content could include the following:
- Respiratory hygiene: The CDC now recommends that all people wear cloth face coverings whenever they leave their homes ("universal masking") in addition to typical guidance for respiratory hygiene (i.e., cover mouth and nose when coughing or sneezing, use tissues and immediately discard the tissue, wash hands or use a hand sanitizer after touching mouth or nose).
- Hand hygiene: Studies show that adequate handwashing (20 seconds with soap) and use of alcohol-based hand sanitizer are key measures for stopping the community spread of infection.
- Physical distancing (based on school guidelines in previous section).
- When to stay at home. This includes assessing paid time off and sick leave policies for staff. To decrease the chance of workplace transmission, these policies should be designed such that employees are not penalized for staying home if they experience symptoms and are not incentivized to continue working if they are sick. The CDC recommends that people stay home if they have ANY of the following:

Major symptoms, as defined by the CDC, include:
- Fever over 100.4 degrees
- New or worsening cough
- Shortness of breath or difficulty breathing
- New loss of taste or smell

Minor symptoms include:
- Fatigue
- Muscle or body aches
- Headache
- Sore throat
- Congestion or runny nose
- Vomiting
- Nausea
- Diarrhea

### High-Risk Identification
School leadership needs to determine policies that accommodate high-risk staff or those with high-risk family members. Staff should be able to self-identify as high risk or as living with a high-risk individual without having to disclose the reasons and without fear of retribution. School leadership needs to determine policies that accommodate high risk students, or those with high risk family members. Educate families on what factors are considered high risk to help families make the best choices for their situations.

The CDC indicates that people of any age with the following conditions are at increased risk of severe illness from COVID-19:
- Cancer
- Chronic kidney disease
- COPD (chronic obstructive pulmonary disease)
- Immunocompromised state (weakened immune system) from solid organ transplant
- Obesity (body mass index of 30 or higher)
- Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
- Sickle cell disease
- Type 2 diabetes mellitus

Based on what is known at this time, the CDC indicates that people with the following conditions might be at an increased risk for severe illness from COVID-19:
- Asthma (moderate to severe)
- Cerebrovascular disease (affects blood vessels and blood supply to the brain)
- Cystic fibrosis
- Hypertension or high blood pressure
- Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
- Neurologic conditions, such as dementia
- Liver disease
- Pregnancy
- Pulmonary fibrosis (having damaged or scarred lung tissues)
- Smoking
- Thalassemia (a type of blood disorder)
- Type 1 diabetes mellitus

Children who have medical complexity, who have neurologic, genetic, metabolic conditions, or who have congenital heart disease might be at increased risk for severe illness from COVID-19 compared to other children.

Staff that have identified as high risk, or who have identified that they have family members who are high risk, need proper support to successfully work from home. Consider stipends or purchasing programs to provide access to necessary technology and equipment and ensure reliable broadband access. To accommodate high risk children and families, consider offering "virtual school:" an enrollment option for online or distance learning for the entire school year.

### Hygiene Practices
Continually reinforce the importance of personal hygiene practices with students and families. Proper handwashing techniques can be taught in class, and consider incorporating frequent handwashing or hand sanitizing into daily classroom routines.

In addition to masks, remind students and families of proper respiratory hygiene: covering your mouth with your elbow when coughing or sneezing and washing your hands after you cough or sneeze.

### Personal Protective Equipment
#### Provide Staff with PPE
Adequate personal protective equipment will significantly reduce the risk of transmission. Provide surgical N95 masks for all staff with regular contact with students that is fit-tested to ensure optimal usage whenever possible. If N95 face masks are unavailable, surgical face masks or cloth face masks can be worn.

Adequate personal protective equipment will significantly reduce the risk of transmission. Schools should consider requiring students to wear cloth face masks inside the school, with removal only allowed while eating or drinking. Consider providing parents and guardians with information on why face masks reduce transmission and how to care for reusable face masks, as well as teaching students how to wear and not to touch or adjust their face masks.

Beyond providing PPE, educate staff on the importance of PPE and the appropriate use. Teach staff how to use and care for N95 or other face masks. Acknowledge staff's concerns with PPE, which may include ability to speak or use facial expressions.

Face shields alone are not considered adequate protection from potential transmission. The CDC does not recommend their use without also wearing a mask because they do not reliably provide adequate coverage of the nose and mouth and can therefore allow for the spread of airborne particles. In addition, those that are designed for more than a single use need to be regularly sanitized, and frequent sanitization can affect their fit or surface integrity. However, clear face shields may be considered appropriate when teaching the deaf or hard of hearing, ESL students, students with disabilities, or young students learning to read.

#### Supply Students with Masks
Masks are an item to be added to school supply lists for students to bring to school with them. Whenever possible, schools should provide students with masks to wear when at school to ensure that all students have them.

#### Ensure Appropriate Mask-Wearing and Respectful Behavior Toward Those Unable to Wear Masks
In general, students aged five and under should not be required to wear a mask unless recommended by local guidelines, and nor should those with severe cognitive or respiratory impairments who may have trouble tolerating a mask or would have difficulty removing a mask without help. Students aged 12 and above should wear masks under the same conditions and circumstances as adults.

Students who are unable to wear a mask may experience stigma or bullying from other students. Schools should develop a plan to help prevent this from happening and for addressing it as necessary.

### Symptom Tracking
Major COVID-19 symptoms, as defined by the CDC, include:
- Fever over 100.4 degrees
- New or worsening cough
- Shortness of breath or difficulty breathing
- New loss of taste or smell

Minor symptoms include:
- Fatigue
- Muscle or body aches
- Headache
- Sore throat
- Congestion or runny nose
- Vomiting
- Nausea
- Diarrhea

Schools should implement a formal symptom tracking process for all staff and students. This can be done on an honor system or staff and students can be required to report their symptoms each day to clear them to attend school. Parents or guardians need to monitor a student's symptoms daily.

Symptom tracking tools such as ProtectWell™ are designed for employers to use CDC guidelines to assess whether a staff member should go to work that day. Staff members complete a brief symptom questionnaire each morning and are cleared to go to work if they are symptom-free. If they report symptoms, the staff member is guided on a course of action, which can include testing or isolating at home.

Schools using symptom tracking platforms should consider positioning a person at each employee entrance to view and scan each person's phone to ensure that they are able to enter that day. It may be necessary to restrict people to a single entrance to reduce the number of people required to conduct scans. Supply these people with appropriate PPE whenever possible.

Policies and procedures should be reviewed to ensure that employees showing symptoms can stay home without negative consequences. School leadership should implement a plan to ensure that adequate substitute teachers are available to step in if a teacher develops symptoms suddenly.

Before returning to school, students and staff must have passed at least three days (72 hours) since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least seven days have passed since symptoms first appeared. Alternatively, students and staff must be symptom-free and have had two negative diagnostic tests at least 24 hours apart.

#### Temperature Checking
Encourage or require staff and students to check their temperature each day. Those with temperatures above 100.4 degrees Fahrenheit should be asked to stay at home. This can be done on an honor system or people can be required to report their temperature each day to clear them for in-person attendance. Alternatively, temperature checkers can be placed at each entrance and can use temporal thermometers to quickly check each person entering. However, precautions are necessary to ensure physical distancing if multiple people queue for temperature checks.

#### Testing
School administrators should consider a testing process for staff and students, either when they present with symptoms or for surveillance testing. While surveillance testing is cost-prohibitive for most schools, school administrators should consider a testing process for those who develop symptoms during the day. Schools could look for community partners, such as health systems, to create a seamless workflow for testing.

Consider testing staff and students with a rapid COVID-19 test at a regular frequency of at least every 48 hours. If there is a known exposure within the school or community, they should undergo testing and follow any exposure mitigation protocols. Rapid tests may include point-of-care polymerase chain reaction (PCR) testing, antigen testing, or loop mediated isothermal amplification (LAMP) testing. Given the need to act quickly based on the results, it is recommended to avoid slower-turnaround testing such as mail-out PCR.

#### Test Pooling
As students are kept together in smaller cohorts, it is possible to pool samples to obtain faster, equally accurate results and reduce the amount of testing supplies needed. Point-of-care PCR testing is an option to test an entire classroom with one test. If positive, the cohort can either be re-tested individually or managed at home following positive COVID guidelines and be taught remotely until isolation is completed. This maintains the in-person experience for the rest of the school.

#### Establish Priority Testing Relationship for Expedited Results
Teaming up with the local health department is essential for testing and contact tracing. When there is an outbreak at a school, partnering with local resources to provide rapid testing for teachers and staff will help keep schools open safely.

### Mental Health Support
Supporting staff, student, and family mental health is critical during this time. Building resilience in staff members is important to help them cope with change, operate continually in high stress environments, and prepare for future stressors. Building resilience in students and families is critical to help them adapt to changes and prepare for future stressors.

School staff need access to multiple mental health support tools, which can include mobile applications, web portals, call centers, and in-person or virtual support services (e.g., support groups or learning communities). Tools should assess the user's level of resilience and provide integrated resources based on the user's baseline resilience level as well as specific concerns or areas of interest. School leadership can ensure that mental health supports are not overwhelming for users and are tailored to the school staff population, including cultural and language considerations. Leadership can promote such tools by reinforcing how they will strengthen and support staff rather than framing the need for tools as a weakness. Combating stigma around mental health is critical to drive adoption of support systems.

Students and families need access to multiple, age-appropriate mental health supports in various mediums, including mobile applications, videos, telephonic, and in-person or virtual support groups. Tools should assess the user's level of resilience and offer suggested resources based on the user's baseline resilience level as well as specific concerns or areas of interest. School leadership should ensure that any mental health supports are not overwhelming for users and are tailored to the school population, including cultural and language considerations.

### Students with Individual Education Plans
Schools need to ensure that students have access to the tools and equipment needed to support their education. Students with physical or cognitive disabilities and students with individual education plans need a customized approach to ensure that their education is accessible. Considerations should be made for students who may not tolerate face masks, such as students with sensory or behavioral issues. Face masks with clear windows are available for staff who work with hard-of-hearing students. Cleaning solutions, particularly those with a strong scent, may negatively affect students who are sensitive to smells.

All students can benefit from behavioral reinforcement of new norms, such as frequent handwashing. Using picture schedules, timers, or other visual cues can help students adjust to new expectations.

### Staff Gatherings
Large face-to-face gatherings of staff should be avoided, and many can be replaced with conference calls or video conferencing. Implement reduced capacity in conference rooms and breakrooms to allow for social distancing, with signage to reinforce capacity limits. If large meetings are unavoidable, all participants should wear masks and keep appropriate distance. Consider holding such meetings outdoors to further reduce risk.

### Special Circumstances
School leadership should consider special circumstances, including two-household families, students who move between homes, students who have high-risk family members at home, and dorm life. Ensure that all individuals who are directly involved in students' lives are aware of relevant policies, procedures, and resources.

## 4. Take Steps to Keep Your Classrooms Open
### Decision-Making on In-Person Education
The Community Action List for Schools (Table #1) provides guidance in how community spread should impact learning models. School administrators should partner with local health departments to ensure access to community viral levels and determine if education models need to change based on community transmission. This grid and the associated metrics should be reviewed daily to ensure ongoing safety.

### Hybrid Models
If community caseload levels are not low enough to keep schools fully open, school administrators can consider various hybrid models to allow smaller groups of students in the school. Hybrid models can provide smaller classes and lower bus ridership. One example is two days per week for students. Half of the student population attends class in the school on Monday and Tuesday, and the other half attends class on Thursday and Friday. If a student is not in the classroom, they should be attending school virtually in the other three days. Wednesdays will be used to clean facilities.

A five-day on, ten-day off model includes half of students attending classes in person on Monday, Tuesday, and Wednesday. The second half of students attend class on Thursday, Friday, and the following Monday, Tuesday, and Wednesday. The halves switch every week to ensure that all students attend five school days over a 14-day period. Under this model, ensure extra attention to cleaning and disinfecting on Wednesday nights and weekends, between group switches. Students continue distance learning on days they are not in school physically.

However, hybrid models are not without risk. Students and families in hybrid models may need additional childcare coverage during remote days. Alternative childcare arrangements may increase exposure to other students, thus increasing the potential for transmission.

Staggering the timing of students' return to full-time in-person education is another crucial consideration for maximizing health and safety. Studies suggest that physical distancing measures have the most sustained effect if return to school is staggered. A staggered return is estimated to significantly reduce the median number of infections throughout the first year). In addition, staggered approaches should start with children who are ten years old or younger as transmissibility and attack rates appear to be lower and less aggressive than in older children.

A "wave model" is a way to execute a staggered re-entry for schools. This entails bringing employees and students back in three- to four-week waves, as long as local infection rates continue to decline (with students continuing distance learning until they return in person). The staggered return will also minimize risk for transmission by allowing for greater physical distancing during the earliest stages of reintegration and ensuring more employees and students rejoin the workspace only as community infection rates decline. The wave model resembles the evidence-based tiered strategy:
- Tier 1: School administrators return to test protocols and ensure safety
- Tier 2: School employees to train on new protocols
- Tier 3: Elementary students return for school-day only activities
- Tier 4: Middle- and high-school students return for school-day only activities
- Tier 5: Resume extracurricular activities

### Auditing Performance
Consider documenting through internal sanitation audits what is being done correctly, as well as areas where improvement is required.

Consider the most effective frequency of social distancing audits, and regularly remind students and staff of the best practices for distancing.

### Sports and Extracurricular Activities
Consider whether sports and extracurricular activities should be allowed to resume. Some sports, such as football or wrestling, have a high degree of contact and are not considered safe. In general, outdoor sports are safer, but no event is completely safe. Even for sports where social distancing can be achieved (e.g., cross country, golf), review whether locker rooms can accommodate social distancing and be frequently cleaned.

Non-sport extracurricular activities need review as well. Many clubs or activities can be modified to achieve social distancing and can continue in an adapted fashion. Activities that include verbal projection—such as choirs, musicals, or performances—have a higher degree of risk. Choir rehearsal, or any group singing activity, creates a high risk for viral transmission.

#### Consider Alternative Methods that would Allow for More Activities
Band, choir, theatre, and physical education all involve students producing more droplets into the air and are thus riskier activities. These activities should be moved outside, where possible, or into larger areas in the school. Reducing group sizes participating in those activities will also help mitigate the risk. Musical instruments should not be shared. These activities may also have to be altered or moved online.

### Changing Models
If cases increase, or if a case is diagnosed within a school, schools may need to shift to distance learning abruptly. School administrators should consider the most effective ways to ensure that staff and families are aware of the potential for abrupt changes, and flexibility should be encouraged. Communicating this possibility throughout the school year will help parents and families prepare, and if the decision is made to move to online learning, communication will be essential not only to help families adjust but also to help them understand why the decision was made.

Students and staff attending classes in person must bring required technology and supplies home each day in case of abrupt school closures.

Once cases are consistently decreasing, schools can gradually reopen, shifting from hybrid models to fully in-person models of education. Beyond caseloads, schools should consider whether all of the factors covered in this document are accounted for to the best of their ability before reopening.

#### Build Distance Learning into In-Person Classrooms
With the possibility of quarantine occurring frequently for whole or partial classes or schools, curriculum needs to be built to ensure students that have to stay home are not having a break in education. Teachers cannot be expected to separately teach students both online and in the classroom. If possible, all homework should be able to be completed and turned in online. For students that must remain at home, there should either be learning exercises that help them learn the concepts for the homework or an ability to watch or listen to the lessons remotely should be offered. Schools should also prepare for the possibility of an entire class moving to quarantine at once. All students and staff should prepare for that class to then move entirely online for learning for the duration of that quarantine period.

#### Maintain Continuous Communication with Parents and Students
The uncertainty of school reopening requires flexibility and clear communication with parents and students. A person or team should disseminate all information to parents and students about COVID-19 policies. All expectations and protocols should be clearly disseminated before the problems arise. All parents should understand how they will be notified and what to do in the event a student tests positive in their child's classroom before that event occurs. While student privacy must be maintained, when there is a suspected or confirmed COVID-19 case in the classroom, students and parents should be notified quickly so they can follow quarantine procedures.

#### Provide Consistent Recommendations to Parents and Students About When to Stay Home
One of the best ways to mitigate outbreaks in the school is to keep students that may have COVID-19 at home. The expectations of when to keep students home should be communicated clearly and consistently. All students with symptoms should stay home until 72 hours after recovery from symptoms. If any household member has tested positive for COVID-19, the student should be in quarantine for 14 days.

### Handling Outbreaks
School administrators need to consider a comprehensive plan for handling outbreaks.

If a student or staff member presents with a temperature or with symptoms at the beginning of the day, keep them either outside or quarantined in the school until they can arrange for medical care.

Quarantine students or staff who develop symptoms during the day until they can seek medical care. If testing is recommended, provide guidance on where and how to get tested and consider arranging access to low- or no-cost testing for students or staff without insurance.

If a case of COVID-19 is confirmed, distance learning may need to be implemented only for that student or staff member's cohort if rapid frequent testing or pooled testing had been implemented. Students and staff within the same classroom as the positive case should be encouraged to seek testing and required to isolate until they have a negative test result or for 14 days.

If a full school closure is necessary, school leadership needs to communicate to students, families, and staff immediately. Local health officials will support school leadership in decision-making on the scope and duration of school closures, including extracurricular group activities, school-based afterschool programs, and large events, and support the school to determine what additional steps are needed to ensure a safe return.

Communication with students, families, and the local community is critical. Consider including messages to counter potential stigma and discrimination while maintaining the confidentiality of the infected student or staff member.

To ensure a safe environment after an exposure, consider closing off areas used by any individual diagnosed with COVID-19 for up to 24 hours to reduce exposure by cleaning crews. Open windows and doors whenever possible to increase air circulation and disinfect surfaces as needed.

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## Safe Health Compact
| School Responsibilities | Student, Faculty, & Staff Responsibilities |
|-------------------------|-------------------------------------------|
| Provide a Safe Environment<br>• Give students, faculty, and staff the tools and equipment to be safe<br>• Follow recommendations from health authorities<br>• Create policies that allow students, faculty, and staff to safely return to school<br>• No retribution for employees unable to return to work – offer equal opportunities to all no matter the worksite | Be safe in your actions<br>• Follow all health guidelines for worksite safety and when to return to school<br>• Complete surveys, testing, and use PPE as required<br>• Be honest on when you should not go to school<br>• Your actions impact not just your health, but that of your co-workers, family, friends, and community |
| Educate<br>• Provide up to date information on community health status<br>• Provide up to date information on school programs and policies<br>• Provide material to increase knowledge of students, faculty, and staff | Be Flexible<br>• Stay up to date with educational material and adjustments to policies<br>• Embrace continuous improvement and understand policies will change as community health risk changes |
| Listen and Communicate<br>• Create a safe environment for student, faculty, and staff communication<br>• Be open and non-judgmental to feedback and ideas<br>• Be transparent in school and district status, health goals, etc | Listen and Communicate<br>• Do not stigmatize or judge co-workers or peers based on their health decisions and return to school status<br>• Give constructive, focused feedback to leaders to help the school do better |
| Lead<br>• Manage with our school values at the core of our decision making | |
||