CHS COVID Self-reporting Form
Please use the following form to log COVID reporting information over the holiday break. This will help us log the information for attendance purposes without a backlog or delay once we return in January. This information is confidential and will only be seen by your school principal, Mrs. Kim Hall, and your school nurse, Mrs. Jennifer Shugarts.
Email address *
Faculty, Staff, or Student Last Name
Faculty, Staff, or Student First Name
First and Last Name of Parent/Guardian of Student:
Cell Phone Number of Parent/Guardian:
Grade Level or Designation
Select any symptoms you are currently experiencing (if applicable)
If yes, date of onset of symptoms:
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DD
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YYYY
Have you received a positive result on a COVID test?
Clear selection
If yes, list test date:
MM
/
DD
/
YYYY
Has a family member or close contact received a positive COVID test result?
Clear selection
If yes, list test date:
MM
/
DD
/
YYYY
What was the date of your last exposure to that family member or close contact?
MM
/
DD
/
YYYY
Reminder
If you have tested positive for COVID-19, please remember to notify anyone with whom you have been in close contact so that they may quarantine as needed and seek medical advice.
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