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Informal Covid-19 Intake Form
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* Required
Date
*
MM
/
DD
/
YYYY
Parent Name
*
Your answer
Parent Phone Number
*
Your answer
Student Name
*
Your answer
Grade
*
06
07
08
09
10
11
12
Last Day Child was in Building
*
MM
/
DD
/
YYYY
Vaccination Status
*
Fully Vaccinated
Not Vaccinated
Day Symptoms started if no symptoms type no symptoms below
*
Your answer
Case Type
*
Positive Test
Direct Exposure to person w/COVID-19
Other:
Any siblings/relatives that work for or attend Pgh. Public Schools that live in your household? If so list their name(s) and school(s). If none type none below.
*
Your answer
Date of Test
*
MM
/
DD
/
YYYY
Type of Test
*
At Home Test
Medical Facility or Lab Test
Results of Test
*
Waiting for results
Positive
Negative
Close contact would be people you were around for 15 minutes or more without your mask and less than 3ft apart. List names below. If none put the word none below.
*
Your answer
Access your work via Schoology, Nurse or admin will inform you of date to return to school, and Ms. Brueckner will adjust attendance. Email all test results to
debeaumont1@pghschools.org
*
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