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COVID-19 Survey
This worksheet is to report illness consistent with COVID-19, a positive COVID-19 test result, or information related to being a close contact of someone else with COVID-19.  This worksheet is applicable to both NOMMA employees and students.  The requested information below will be used to comply with mandatory Louisiana Department of Health school reporting requirements.  
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Phone Number *
First Name *
Last Name *
Date of Birth *
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Today's Date *
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Role *
Parish that the case resides in: *
Gender of case *
Ethnicity of case *
Race of case *
Grade
Received molecular/viral laboratory testing for COVID-19 (SARS-CoV-2)? *
If yes, what was the result?
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Isolation (when someone has tested positive for COVID-19)
The earliest date this person can end isolation is 10 days after his/her test date (if asymptomatic) or onset date (if symptomatic), provided his/her symptoms improve and no fever reducing medication has been used during the previous 24 hours.
Select the symptom(s), if any, that are felt.
When did the first symptom begin?
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Date this person was last at NOMMA? *
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Does this person currently participate in a sport or other school activity? *
List the sport and/or school activity the person participates.  If this person does not participate in a sport or other school activity, please write "N/A". *
Do you ride a bus or carpool to and from school? *
Quarantine (when someone is a close contact of a COVID-19 case)
Fully vaccinated individuals who are asymptomatic do not have to quarantine.  Quarantine could apply to unvaccinated individuals or vaccinated individuals who are experiencing COVID-19 symptoms (see LDH Decision Trees). The length of quarantine varies.  A close contact is defined as being within 6 feet of a confirmed positive COVID-19 case for more than 15 minutes over a 24-hour period.
If you are reporting you were a close contact to a Positive COVID Person, please list the date of your last known contact with that person.
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Was there a close contact of another person with COVID-19 at NOMMA? *
If yes, please provide name of this person and phone number.
Was there a close contact of a person with COVID-19 in the community? This includes, but not limited to, any person in the student's or employee's household who is NOT another student/faculty/staff of the school. *
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