COVID-19 Reporting Form

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Please use this form to gather all essential information about the reporting person who is experiencing COVID symptoms and/or has received a positive COVID-19 test result. This 2 min survey will allow us to take steps to monitor our Students and Staff to take any necessary precautions.

Today's Date *

YYYY

Who is completing this form? (First and Last name) *

First and Last name of the reporting person experiencing COVID symptoms or having received a positive COVID test result - option to leave blank if they wish to remain anonymous.

Notes:

Are you/they currently experiencing any of the following COVID-19 symptoms? Please check all that apply. *

Fever (100.4°F or higher), chills, repeated shaking with chills, or muscle pain

Persistent headache or sore throat?

A new cough that you cannot attribute to another health condition?

New shortness of breath that you cannot attribute to another health condition?

New loss of taste or smell?

I am not experiencing ANY COVID-19 Symptoms

Required

If symptomatic, what was the date of first experiencing symptoms?

YYYY

Have you/they been tested for COVID-19? *

Yes

If you/they were tested, what was the date of the most recent COVID-19 test?

YYYY

If you/they were tested, what were the results of the COVID-19 test?

Positive for COVID-19

Negative for COVID-19

Unknown or still waiting on results

Other:

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To the best of their knowledge, do they recall if they had CLOSE CONTACT: (Defined as being within 6 feet of an individual(s) for at least 15 min (with or without a mask) with any staff or students? Please list?

THANK YOU! We are in this together and we deeply appreciate you. Well wishes for a speedy recovery! If you/they are open to us reaching out, please leave a contact phone number in the space below.

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