COVID-19 Reporting Form
Please use this form to report any student or staff member:

1) who is experiencing symptoms of COVID-19,
2) who has received a diagnosis of COVID-19 confirmed by a test or
3) who has been in close contact with a person who has a positive COVID-19 test.

If this report is regarding a student, please complete a form for each student in the home.

A campus nurse or the MISD Director of Health Services may follow up on this report to gather more details or to provide instructions.

First and last name of student or staff member this report is about: *
Who should be contacted if MISD has questions about this report? Please include name and phone number. *
The subject of this report is a: *
Name of School Campus or District Building *
Grade Level (if a student)
Face to Face or Virtual Learner? *
Does the subject of this report live in the same home as someone who has tested positive for COVID-19? *
Has the subject of this report been in close contact with someone who has tested positive for COVID-19? *
If you answered yes to the previous question, describe the circumstances and when the close contact occurred. *
Is the subject of this report currently experiencing COVID symptoms? *
If you answered yes to the previous question, when did the symptoms begin?
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Select all symptoms the subject is experiencing:
Date of COVID test, if taken
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Result of COVID Test *
Has the subject of this report been told to quarantine by a medical professional? *
What date will the quarantine period end, if applicable?
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Is there any additional information you would like to provide?
Submit
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