Request edit access
Thomas Lake Student Reporting Form for COVID-19 (outside of school day hours)

Sign in to Google to save your progress. Learn more
Email *
If it is outside of the school day or weekend and you suspect that your child has COVID-19, please complete the this form.
If it is during the school day and you suspect that your child has COVID-19 or has been confirmed of having COVID-19, please call our school at (651-683-6980) and ask to speak to our school nurse.
This questionnaire asks about student health and potential exposure to COVID-19. The data collected may be classified as private under the MN Government Data Practices Act. The data you share may be used for the following purposes:

1.) To screen for potential COVID-19 related symptoms and exposures in an effort to avoid the spread of COVID-19;
2.) To determine when it is safe for the student to return to school;
3.) If the student has tested positive for COVID-19, the information shared may also be used to notify other individuals who may have been exposed to COVID-19 through their contact with the student. If this is the case, the student’s name will not be used with these individuals.

You are not legally required to provide this data. However, if you decline to provide the information requested, the student may not be admitted into the school. Data collected may be shared with school district staff, and other persons or entities authorized by law, including public health authorities. De-identified data may also be used with individuals who may have been exposed to COVID-19 through their contact with the student.
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Name(s) *
Phone Number *
My child has the following symptoms of Covid 19 *
Required
Symptoms first appeared on what day? *
MM
/
DD
/
YYYY
My child has received a positive test result for COVID-19 *
Please list any additional family members that attend a school in District 196 (provide name and school):
Please list all Thomas Lake sports, activities, community education classes, Thomas Lake Tier 1 Childcare, or SAC that your child participates in:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Independent School District 196. Report Abuse