COVID-19 Reporting Form

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Please use this form to report if your child:

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

A campus nurse may follow up on this report to gather more details or to provide instructions.

Student First Name *

Student Last Name *

Grade Level *

Parent Full Name *

Parent Email *

Parent Phone Number *

Last Date in School *

YYYY

My child *

1. is experiencing symptoms of COVID-19

2. has received a diagnosis of COVID-19 confirmed by a test

3. has been in close contact with a person within our household who has a positive COVID-19 test

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