Reporting COVID 19 - Student Form
This form is only to be completed if you have tested positive, you have been told by a medical professional that you are a symptomatic (presumed) positive person, or you are a close contact to a COVID positive person.

If you have additional questions or concerns, please contact the school office or your health care provider.
Name of Student *
Please choose the one that best describes the situation. The student has: *
Please provide the date the quarantine began. *
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Student Date of Birth *
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Name of School *
Grade Level *
Name of Person Completing Form and Relationship to Student *
Best Phone Number to Reach You *
Does the student have any family members in Kirkwood Schools? *
If yes, please provide the name and school of all persons who live in the household with you.
When was the student last on campus? *
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If the student was exposed to a person who is COVID-positive when were they last with the COVID-positive person?
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What is the name of the COVID positive Person?
How long was the student with the COVID-positive person? (check all that apply) * *
Required
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