COVID Case Reporting
IMPORTANT:
Please keep all children in the household home from school until the district reviews the form. Once the district receives and reviews the form a school official will be in contact with you to discuss your child's return to in-person learning. Dates and protocols for both the positive child and close contacts within the home will be provided at that time.

PLEASE NOTE:
If you are reporting a Covid Case - the First Date of Symptoms MUST be answered.
If you are reporting a Close Contact Case - Either the Date of Contact for a Community Contact or the Date of first Symptoms for the Household Member MUST be answered.

An email will be automatically generated based on your responses.  If the dates are not entered properly on the form, the dates in the email will not be correct.
Sign in to Google to save your progress. Learn more
Email *
Please select which case you are reporting: *
Child Name (Last, First Name) *
School *
Teacher
Date of Birth
MM
/
DD
/
YYYY
Parent Name (Last, First Name) *
Home Address (Street Address, Town, State, Zip)
Phone Number
Date symptoms began:
MM
/
DD
/
YYYY
Date of COVID test:
MM
/
DD
/
YYYY
Last date the student was in school (in person):
MM
/
DD
/
YYYY
Is your child considered fully vaccinated?
Clear selection
Date for vaccine dose #1:
MM
/
DD
/
YYYY
Date for vaccine dose #2:
MM
/
DD
/
YYYY
Has your child recovered from COVID within the last 90 days?
Clear selection
If so, when did your child have it?
MM
/
DD
/
YYYY
Was your child considered a close contact from school?
Clear selection
Has anyone in the household tested positive for COVID? NOTE* If anyone in the household is awaiting test results or has a positive case in the home the child should NOT attend school.
Clear selection
What was the date of the test?
MM
/
DD
/
YYYY
Was your child a close contact from:
Clear selection
If this is a Community Contact, what was the date of contact?
MM
/
DD
/
YYYY
If this is a Household Contact, what is the date the symptoms started for the household member?
MM
/
DD
/
YYYY
Does your child have siblings in the district? *
Sibling #1 (Last, First Name)
Sibling #1 (School)
Clear selection
Sibling #2 (Last, First Name)
Sibling #2 (School)
Clear selection
Sibling #3 (Last, First Name)
Sibling #3 (School)
Clear selection
Sibling #4 (Last, First Name)
Sibling #4 (School)
Clear selection
Mode of Transportation
Clear selection
Does your child attend before/after care? *
Is the positive person able to isolate from the rest of the house not sharing bathroom, bedroom, or eating with other siblings in the household?
Clear selection
Can your child wear a well fitted mask at home? In school?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Waterford Township School District. Report Abuse