COVID-19 - Mandated Disclosure Form

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Jacquelyn Y. Kelley Discovery Charter School (JYKDCS) requires that staff, students, parents, and any service providers complete this form to disclose whether they are in self-quarantine for any of the reasons listed below.

The information will be kept confidential in accordance with HIPAA and FERPA; will be used to assist HR in tracking employees’ use of sick leave; will help Student Development understand the impact of students; and will aid the Pennsylvania Department of Health in any potential contact investigation when new coronavirus cases are identified.

For employees, disclosure will have no implication on employee's work status.

Failure of any persons to disclose, may result in immediate disciplinary actions.

Email *

Last Name *

First Name *

Date of Birth *

YYYY

Home Address *

I currently reside in the city of Philadelphia *

Yes

If no, please list your current residence (city and state) *

Personal Email *

Mobile Number *

Role *

Student

Staff

Service Provider

Other

Grade *

Kindergarten

First

Second

Third

Fourth

Fifth

Six

Seventh

Eighth

I am in self-quarantine because *

I have been diagnosed by a health care provider with a positive COVID-19 test.

I have been diagnosed by a health care provider with COVID-19 WITHOUT a positive test but based on symptoms.

I have NOT been diagnosed by a health care provider with COVID-19, but I do have symptoms of the disease.

I have NOT been diagnosed by a health care provider with COVID-19, but have been exposed to someone who does have a positive COVID-19 test, and I am NOT symptomatic.

Required

Date of quarantine start *

YYYY

Are you experiencing symptoms? *

Yes

If yes, onset date.

YYYY

Date of testing

YYYY

Location of testing site

What was the last day you were at the school? *

YYYY

A copy of your responses will be emailed to the address you provided.

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