Student COVID Data Reporting Form
If you are reporting more than one student, please fill out one form per student. Thank you!

This form was updated on 1/22/21.
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Student First Name *
Student Last Name *
Student ID *
Your Name *
Please record your first and last name.
I am reporting a case of COVID-19 or quarantine as a *
Your Email Address *
Your Phone Number
Student's Current Status *
A positive case is defined by a first-hand account of a person who has received a positive test that has been conducted by a medical expert. Close contact exposure is when the two people are within 6 feet of each other for more than 15 minutes.
Date tested, if applicable
MM
/
DD
/
YYYY
If tested, the result was
Clear selection
Current Symptoms *
Check all that apply
Required
Parent / Guardian Names
Date of Symptom(s) Onset
If the student has symptoms, please indicate the day symptoms began.
MM
/
DD
/
YYYY
Date of Exposure
Enter the last day the student was exposed to someone who was COVID positive.
MM
/
DD
/
YYYY
Where was the student most likely exposed? *
Building *
Grade Level *
Please list the names of siblings or other Mason students living in the home.
Is your child learning in-person or online? *
Is the student currently in option 1 (in-person) or option 2 (online)?
Current Extra-Curricular Activities
Please include any and all of the student's extra curricular activities that you are aware of at this time - teams, clubs, groups, etc.
Additional Notes
If there are additional details you feel are important, please do so here.
The student
Does the student intend to participate in remote learning while at home? *
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