Informal Covid-19 Intake Form
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Date *
MM
/
DD
/
YYYY
Parent Name *
Parent Phone Number *
Student Name *
Grade *
Last Day Child was in Building *
MM
/
DD
/
YYYY
Vaccination Status *
Day Symptoms started                                                            if no symptoms type no symptoms below *
Case Type *
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. *
Date of Test *
MM
/
DD
/
YYYY
Type of Test *
Results of Test *
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. *
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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