Pelham Positive COVID Case Reporting Form

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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 jhuezo@pelhamschools.org.

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

Pelham Public Schools

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) *

Colonial

Hutchinson

Prospect Hill

Siwanoy

Middle School

High School

Required

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. *

No siblings in Pelham Schools

Colonial

Hutchinson

Prospect Hill

Siwanoy

Middle School

High School

Required

Is there additional information you would like to provide?

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