Breakthrough Public Schools COVID-19 Employee Reporting

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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.

Email *

What is your full name? *

What is your primary school/location? *

Cliffs

Woodland Hills

Willard

Citizens Southeast Campus

Citizens East Campus

Citizens Hampden Campus

Breakthrough Office

FOB Office

Required

What is the best phone number to reach you? *

What is your job title? *

Have you been vaccinated? *

Yes

Required

What was the date of your second vaccination? Or the date of your first vaccination if you received the J&J vaccine.

YYYY

Have you received a booster shot (Pfizer/Moderna) or second dose (J&J)? *

Yes

N/A

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. *

I have received a positive COVID-19 test or a confirmed COVID-19 diagnosis from a medical professional

I am experiencing COVID-19-like symptoms AND have reported to a Breakthrough schools building within the last 14 calendar days

I am being tested for COVID-19 AND have reported to a Breakthrough schools building within the last 14 calendar days

I have been exposed to someone who has tested positive for COVID-19 AND have reported to a Breakthrough building within the last 14 days and have not already been contacted by Breakthrough about this contact

Other:

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