Pelham Positive COVID Case Reporting Form
Dear Families and Staff,

In an effort to make our contact tracing efforts more efficient, we ask that you report positive COVID-19 cases using this Google Form instead of notifying your building principal or school nurse. The information submitted on this form will be kept confidential. After submitting the form, please email a copy of the result to the COVID Coordinator, Jackie Huezo, at

Thank you very much for your partnership in keeping our school community healthy and safe.

Pelham Public Schools
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Email *
Name of the person completing this form (Last, First): *
Best contact number (xxx-xxx-xxxx) *
Last name of the person who tested positive: *
First name of the person who tested positive: *
School Attended (Check all that apply) *
The first day of COVID symptoms (mm/dd/yy) or please write "NA" if asymptomatic *
The date of COVID test (mm/dd/yy): *
The last day the positive individual was in school in person (mm/dd/yy): *
If the positive individual has a sibling(s) in our school(s), please check the school(s) of attendance. *
Is there additional information you would like to provide?
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