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.
* Required
Email address
*
Your email
Faculty, Staff, or Student Last Name
Your answer
Faculty, Staff, or Student First Name
Your answer
First and Last Name of Parent/Guardian of Student:
Your answer
Cell Phone Number of Parent/Guardian:
Your answer
Grade Level or Designation
9
10
11
12
Faculty
Staff
Select any symptoms you are currently experiencing (if applicable)
new loss of taste or smell
new cough
fever
chills
muscle or body aches
shortness of breath or wheezing
chest pain
runny nose or congestion
sore throat
headache
diarrhea/abdominal pain/persistent vomitting
fatigue
dizziness
not currently experiencing symptoms
If yes, date of onset of symptoms:
MM
/
DD
/
YYYY
Have you received a positive result on a COVID test?
Yes
No
Clear selection
If yes, list test date:
MM
/
DD
/
YYYY
Has a family member or close contact received a positive COVID test result?
Yes
No
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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