Covid Intake Form-(Positive Cases of Covid-19)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Your email address is automatically collected when completing this form. Please add the information regarding the positive case below.

Email *

Class *

First Name of Student or Staff Member *

Last Name of Student or Staff Member *

Date of Symptoms (if applicable)

YYYY

Date of COVID-19 Test: *

YYYY

Test Type *

At Home Test

Lab Confirmed Test

Surveillance Test (In-school Testing)

Last day in the school building *

YYYY

OSIS# for Student OR Employee ID/Reference # for Staff

Does the student attend after school?

Yes

Clear selection

Does the child have a sibling(s)?

Yes

Clear selection

If yes, are they vaccinated?

Yes

Clear selection

If yes, do you know the sibling's name and class?

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

This form was created inside of NYC Department of Education.

Does this form look suspicious? Report