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BCS Confidential COVID-19 Reporting Form
Staff, students, or parents/guardians:

Please use this document to report confirmed or suspected COVID-19 illness, symptoms, or exposure . If you are experiencing COVID-19 illness or possible exposure, please CONTACT YOUR MEDICAL PROVIDER right away.

Please fill out this form for each individual person or possible exposure you are reporting. We can not stress enough that this information will be kept confidential and it is needed solely to identify disease prevalence and spread in our schools and district's campuses.
Today's Date *
MM
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DD
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YYYY
Person reporting *
Phone number *
Name of person confirmed or suspected of having COVID-19 *
Grade *
Required
Student's homeroom or grade level teacher: *
EXPOSURE:
An exposure occurs when someone has close physical contact to:

(1) a person with COVID-19 who has symptoms (in the period of two days prior to symptom onset until the infected person completes their home isolation) or 2) a person who tested positive for COVID-19 but has not had any symptoms (in the two days before test specimen collection until the person with a positive test completes their home isolation).

The wearing of a face mask (by a person with active COVID-19, a person with pre-symptomatic or asymptomatic COVID-19, or a person without COVID-19) greatly decreases the risk of spreading or contracting the virus. However, wearing a face mask has no bearing on the determination of close contact or exposure.

Close contact is determined solely by (< 6 feet) and time (> 15 minutes cumulatively) and exposure is determined by close contact to a person with COVID-19 symptoms or a positive COVID-19 test.
Do you need to report that you or someone else has had exposure to COVID-19 (as noted by the definition above)? *
If you are reporting an exposure, please describe the incident of suspected exposure. Add details such as, was the person you are reporting properly wearing a mask? Were you properly wearing a mask? How close were you to others? Length of time exposed? Why do you think there has been an exposure? Please provide names of any involved with the exposure. *
If you are reporting suspected or confirmed COVID-19 illness, what symptoms if any are being experienced? Please check all that apply. *
Required
Was the student or staff member tested for COVID-19? *
If testing results have been received please indicate positive or negative for COVID-19.
Clear selection
Has a medical provider been consulted? *
If applicable, have you been given any work or school restrictions by your medical provider? We will ask that you provide the school with written documentation from your medical provider. *
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