[Local Public Health Letterhead]
[Date]
Dear District Superintendent, Charter School Director, or Private School Head of School:
On [Date of Monitoring List Placement], the California Department of Public Health (CDPH)
placed [Name] County on its monitoring list. On July 17, 2020 Governor Gavin Newsom
announced that if a county has been on the monitoring list within the prior 14 days, a school
must conduct distance learning only, until the county has been off the monitoring list for at least
14 days.
In counties on the monitoring list, CDPH guidance allows a district superintendent, private
school principal/head of school, or executive director of a charter school (hereinafter
superintendent) to apply for a waiver from the local health officer to open an elementary school
for in-person instruction. This waiver is applicable only for grades TK-6, even if the grade
configuration at the school includes additional grades.
When applying for the waiver, the superintendent must submit to the local health officer
evidence of (1) consultation with labor and parent organizations and (2) publication of the
elementary school reopening plans on the website of the local educational agency (or
equivalent).
The local health officer then reviews the application and reopening plan (along with local
community epidemiological data), makes a determination whether to grant or deny the waiver,
and consults with CDPH regarding that determination. Elementary schools in counties on the
monitoring list within the prior 14 days may not open for in-person instruction until they have
received approval of a submitted waiver from the local health officer.
In order to apply for a waiver, please complete and submit the attached Application Cover Form.
An application must contain:
•

•

Attestation that the superintendent (equivalent or designated staff) has consulted with all
parent and labor organizations at each school site for which an application is being
submitted. If no labor organization represents the school site staff, then consultation with
school site staff is sufficient.
Confirmation that elementary school reopening plans have been published on the
website of the local educational agency (or equivalent). Reopening plans must address
the components in the CDPH guidance for schools and school-based programs (which
are also listed in the attached Application Cover Form).

Applications and all supporting documents should be submitted to the local health officer at
least 14 days prior to the desired reopening date to [Email Address].
Sincerely,
[Name]
[Title]

[Health Organization]

 Waiver Application Cover Form
(for use by a Local Education Agency or equivalent)
Please submit one application for each local educational agency or equivalent. If
applying on behalf of a school district please submit one application for elementary
schools in the district that are seeking to reopen for in-person instruction. If applying for
an independent, private, faith-based, or charter school, please submit an application for
each school.
Background Information
Name of Applicant (Local Educational Agency or Equivalent):
_______________________
School Type:
______ Traditional Public School
______ Charter School
______ Private, Independent, or Faith-Based School
Number of schools: ______

Enrollment: ______

Superintendent (or equivalent) Name:
Address:

___________________________________

__________________________
__________________________
__________________________

Grades/Number of Students Proposed to be Reopened:
TK

K

1st

2nd

3rd

4th

5th

6th

Date of Proposed Reopening:

___________________________

Name of Person Completing Application:

___________________________

Phone Number:

_______________________

Email:

_______________________

Signature:

_______________________

Date: __________

 I.

Consultation
Please confirm consultation with the following groups:
Labor Organization
Name of Organization(s) and Date(s) Consulted:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Parent and Community Organizations
Name of Organization(s) and Date(s) Consulted:
________________________________________________________________
________________________________________________________________
________________________________________________________________
If no labor organization represents staff at the school, please describe the
process for consultation with school staff:
________________________________________________________________
________________________________________________________________
________________________________________________________________

II.

Elementary School Reopening Plans
Please confirm that elementary school reopening plan(s) addressing the
following, consistent with guidance from the California Department of Public
Health and the local health department, have been published on the website of
the local educational agency (or equivalent):
 Cleaning and Disinfection: How shared surfaces will be regularly cleaned and
disinfected and how use of shared items will be minimized.
 Cohorting: How students will be kept in small, stable, groups with fixed
membership that stay together for all activities (e.g., instruction, lunch, recess)
and minimize/avoid contact with other groups or individuals who are not part of
the cohort.
 Entrance, Egress, and Movement Within the School: How movement of
students, staff, and parents will be managed to avoid close contact and/or mixing
of cohorts.

  Face Coverings and Other Essential Protective Gear: How CDPH’s face
covering requirements will be satisfied and enforced.
 Health Screenings for Students and Staff: How students and staff will be
screened for symptoms of COVID-19 and how ill students or staff will be
separated from others and sent home immediately.
 Healthy Hygiene Practices: The availability of handwashing stations and hand
sanitizer, and how their use will be promoted and incorporated into routines.
 Identification and Tracing of Contacts: Actions that staff will take when there
is a confirmed case. Confirm that the school(s) have designated staff persons to
support contact tracing, such as creation and submission of lists of exposed
students and staff to the local health department and notification of exposed
persons. Each school must designate a person for the local health department to
contact about COVID-19.
 Physical Distancing: How space and routines will be arranged to allow for
physical distancing of students and staff.
 Staff Training and Family Education: How staff will be trained and families will
be educated on the application and enforcement of the plan.
 Testing of Students and Staff: How school officials will ensure that students
and staff who have symptoms of COVID-19 or have been exposed to someone
with COVID-19 will be rapidly tested and what instructions they will be given
while waiting for test results. Describe how staff will be tested periodically to
detect asymptomatic infections.
 Triggers for Switching to Distance Learning: The criteria the superintendent
will use to determine when to physically close the school and prohibit in-person
instruction.
 Communication Plans: How the superintendent will communicate with students,
staff, and parents about cases and exposures at the school, consistent with
privacy requirements such as FERPA and HIPAA.

 Additional Resources:
CDPH and Cal/OSHA Guidance for Schools and School-Based Programs
https://files.covid19.ca.gov/pdf/guidance-schools.pdf
California Department of Education Stronger Together: A Guidebook for the Safe
Reopening of California’s Public Schools
https://www.cde.ca.gov/ls/he/hn/strongertogether.asp
CDPH COVID-19 and Reopening In-Person Learning Framework for K-12 Schools in
California, 2020-2021 School Year
https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/COVID
-19/Schools%20Reopening%20Recommendations.pdf