CCISD COVID 19: Self-Report and Test Request
Please submit the form below for all issues related sick leave including requests for testing. This means you are unable to work in your assigned location and need leave or permission to work remotely. *** You must contact the personnel office to receive permission to return to work.*** Be sure to click the last button and have a copy emailed to your account for your records.
Employee Last Name
Employee First name
Nutrition Services and Maintenance/ Transportation : please contact your supervisor.
What is your position in the district?
Please describe your most recent contact with students or staff including dates.
Date (s) to be absent if applicable.
Total number of days absent can not be determined at this time. You must have the approval to return to work from the personnel office.
In understand I MAY NOT work from home unless I receive written permission from the Personnel Office .
ALL EMPLOYEES: I understand that my supervisor and I must have written permission to return to work from the personnel office.
I understand that documentation for COVID testing, COVID related leave and remote work is required.
Reason for this submission
I am notifying the district of a COVID 19 issue either positive, exposed or close contact.
My supervisor has directed me to leave my scheduled position due to a COVID 19 related issue
I am requesting a COVID TEST : Reason will be recorded below.
Other- through the personnel office
Please check all that apply
I have been in direct contact with a household member who is lab tested positive for COVID 19 or has symptoms
I have been lab-tested positive for COVID 19 or have symptoms for COVID 19
I have been in direct contact with a non-household member who is lab tested positive for COVID 19 or has symptoms of COVID 19
My child's day-care / child care provider has closed due to COVID 19
I have traveled out of the country or to a CDC identified hot zone.
Other, please contact Kelly Taylor at
Reason for absence, testing request or other...
Please include a phone number and email where you can be reached.
You are requesting to .......
Receive permission to work from home
Take personal or sick leave
Be scheduled for a free, non invasive, voluntary COVID Test
Be compensated by the CARES ACT due to COVID 19- a brief conversation will be needed about leave.
Please check that you have read this leave request and agree by checking the box below. This will serve as your electronic signature. Someone will contact you shortly with a decision regarding leave. You must secure permission to return to work from the personnel office.
I am requesting to work remotely.
School is not in session at this time.
I am requesting leave and am unable to work in-district or remotely. This will serve as my electronic agreement.
I will know more about what to request after the test results arrive.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Calhoun County ISD.