Breakthrough Public Schools COVID-19 Employee Reporting
This form is designed to collect information from Breakthrough Public Schools employees or contracted staff who:

1.Have tested positive for or received a confirmed diagnosis of COVID-19

OR

2. Are experiencing COVID-19-like symptoms

OR

3. Have known close contact with an individual who has tested positive for COVID-19. ("Close contact" with someone with COVID-19 is defined as being within 6 feet of that person for at least 15 minutes within 48 hours of symptom onset, while UNMASKED.)

Please ONLY complete this form if you meet the criteria listed above.

All other questions and comments can be submitted via email to hccovid@breakthroughschools.org.

Note that all information submitted through this form will be kept confidential. No identifying information will be shared outside of HC or the Operations leadership team without your express written permission.
Sign in to Google to save your progress. Learn more
Email *
What is your full name? *
What is your primary school/location? *
Required
What is the best phone number to reach you? *
What is your job title? *
Have you been vaccinated? *
Required
What was the date of your second vaccination? Or the date of your first vaccination if you received the J&J vaccine.
MM
/
DD
/
YYYY
Have you received a booster shot (Pfizer/Moderna) or second dose (J&J)? *
Required
COVID-19 Symptoms and Close Contact
The CDC reports the following symptoms of COVID-19:
Feeling feverish or a measured temperature greater than or equal to 100 degrees Fahrenheit
Loss of taste or smell
Cough
Difficulty breathing
Shortness of breath
Headache when in combination with other symptoms
Chills
Sore throat
Shaking or exaggerated shivering
Significant muscle pain or ache
Nausea, vomiting, or diarrhea

"Close contact" with someone with COVID-19 is defined as working within 6 feet of that person for at least 15 minutes within 48 hours of symptom onset, while UNMASKED.
Which of the following applies to you? If more than one option applies to you, select the option most relevant for your situation right now. *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Breakthrough Schools. Report Abuse