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STAFF Reporting COVID-19 Symptoms
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* Required
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
School/Location (Check all that are appy)
*
Dutch Neck Elementary School
Maurice Hawk Elementary School
Town Center Elementary School
Wicoff Elementary School
Millstone River School
Village School
Community Middle School
Grover Middle School
High School North
High School South
505 Village
Central Office
Required
What is your position/working assignment for WW-P
*
General education teacher
Special education teacher
Special education other certificated role (OT/PT/CST)
Special area teacher
Teacher Resource Specialists/Tech Resource Specialists
Secretary
Administrator
Special education instructional assistant
Cafeteria, bus, or playground aide
Bus driver
Buildings and Grounds
Other:
Assignment
*
In-person
Hybrid Assignment (In-person)
Virtual Assignment (In-person)
Virtual Assignment (From home)
Non-teaching In-Person
Non-teaching from Home
Today's Date
*
MM
/
DD
/
YYYY
Reason for concern
*
Positive COVID-19 test result (PCR or Rapid Test)
Positive COVID-19 test result (Home Test)
Suspected diagnosis of COVID-19
COVID symptoms
Close contact with someone who tested positive for COVID-19 (Close contact is defined as within 6 ft. of an individual for 15 minutes or longer in a 24-hour period.)
Close contact with someone who MAY be COVID-19 positive (Close contact is defined as within 6 ft. of an individual for 15 minutes or longer in a 24-hour period.)
Someone in your household is diagnosed with COVID-19
If symptomatic, please click all symptoms that apply (2 or more from this section are required for quarantine)
Fever
Chills
Rigors (shivers)
Myalgia (muscle aches)
Headache
Sore throat
Nausea or vomiting
Diarrhea
Fatigue
Congestion or runny nose
If symptomatic, please click all symptoms that apply (1 from this section are required for quarantine)
Cough
Shortness of breath
Difficulty breathing
New loss of smell
New loss of taste
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?
*
Yes
No
Other:
If a COVID test has been conducted, what type of test.
PCR
Rapid
Home
Other:
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
/
DD
/
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.)
*
Your answer
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.)
Your answer
Email address of building principal
Your answer
Email address of supervisor
Your answer
Are you vaccinated
*
Yes
No
Date you received last vaccination (non-booster) shot
MM
/
DD
/
YYYY
Type of Vaccine
Pfizer
Moderna
J & J Janssen
Clear selection
Are you boosted
*
Yes
No
Date you received booster shot
MM
/
DD
/
YYYY
Type of Booster
Pfizer
Moderna
J & J Janssen
Clear selection
Best phone number to reach you (###) ###-####
*
Your answer
Best email address to reach you
*
Your answer
Has the Health Department contacted you
Yes
No
Clear selection
Any additional pertinent information
Your answer
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