STAFF Reporting COVID-19 Symptoms
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Email *
First Name *
Last Name *
School/Location (Check all that are appy) *
Required
What is your position/working assignment  for WW-P *
Assignment *
Today's Date *
MM
/
DD
/
YYYY
Reason for concern *
If symptomatic, please click all symptoms that apply (2 or more from this section are required for quarantine)
If symptomatic, please click all symptoms that apply (1 from this section are required for quarantine)
If symptomatic, date symptoms began
MM
/
DD
/
YYYY
If appliable, date of last contact with someone diagnosed/suspected of having COVID-19
MM
/
DD
/
YYYY
Have you had a COVID test? *
If a COVID test has been conducted, what type of test.
Clear selection
If a COVID test has been conducted, what was the date of the test?
MM
/
DD
/
YYYY
Last date physically present in District *
MM
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DD
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YYYY
Names of staff members in close contact since two days before symptoms began. If no close contacts with staff members enter N/A. (Close contact is defined as within 6 ft. of an individual for 15 minutes or longer in a 24-hour period.) *
Names of students in close contact since two days before symptoms began. (Close contact is defined as within 6 ft. of an individual for 15 minutes or longer in a 24-hour period.)
Email address of building principal
Email address of supervisor
Are you vaccinated *
Date you received last vaccination (non-booster) shot
MM
/
DD
/
YYYY
Type of Vaccine
Clear selection
Are you boosted *
Date you received booster shot
MM
/
DD
/
YYYY
Type of Booster
Clear selection
Best phone number to reach you (###) ###-#### *
Best email address to reach you *
Has the Health Department contacted you
Clear selection
Any additional pertinent information
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