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COVID-19
Student Reporting Form / Forma para Reportar que su Hijo(a) Tiene COVID
Please fill out the form below when a student has tested positive for COVID.
Si su estudiante dio positivo en la prueba de COVID llene esta forma.
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* Indicates required question
Email or contact number / Correo electrónico o teléfono
*
Your answer
Student's last name /
Apellido del estudiante
*
Your answer
Student's first name / Nombre del estudiante
*
Your answer
Date of Birth /Fecha de nacimiento
*
MM
/
DD
/
YYYY
School / Escuela
*
Adelante Selby
Clifford
Garfield
Henry Ford
Hoover
Kennedy
McKinley
North Star
Orion
Roosevelt
Roy Cloud
Taft
Please indicate the names of teachers and staff your child interacts with at school. / ¿Con qué maestros o empleados convivió su hijo(a) en la escuela?
*
Your answer
Grade / Grado
*
Pre-school
TK
Kinder
1st
2nd
3rd
4th
5th
6th
7th
8th
Classroom # / Número de salón
Your answer
Date of positive test / Fecha de la prueba positiva
*
MM
/
DD
/
YYYY
Type of test/Tipo de prueba
*
Rapid Antigen / Prueba Rápida de Antigeno
PCR Test / Prueba PCR
At Home Test / Prueba Casera
Other:
When was the student last on campus?
¿Cuándo fue la última vez que el estudiante estuvo en la escuela?
*
MM
/
DD
/
YYYY
Please check any symptoms you are experiencing / Marque todos los síntomas de su estudiante
*
Headache / Dolor de cabeza
Fever or chills / Fiebre o escalofríos
Cough / Tos
Shortness of breath or difficulty breathing / Falta de aliento o dificultad para respirar
Fatigue (tiredness) / Fatiga (cansancio)
Muscle or body aches / Dolor muscular o del cuerpo
New loss of taste or smell / Nueva perdida del gusto o del olfato
OptionSore throat / Dolor de garganta
Congestion or runny nose / Nariz tapada o con secrecion nasal
Nausea or vomiting / Nausea o vómito
Diarrhea / Diarrea
None / Ninguno
Other:
Required
Additional information / Otra información
Your answer
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