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
Please record your first and last name.
I am reporting a case of COVID-19 or quarantine as a
School Staff Member
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.
Isolation - COVID Positive
Quarantine - Close Contact Exposure
Quarantine - Travel
Quarantine - Waiting on Test Results
Quarantine - Other
Date tested, if applicable
If tested, the result was
Check all that apply
Congestion or runny nose
Loss of taste or smell
Muscle or body aches
Nausea or vomiting
No symptoms at this time
Shortness of breath or difficulty breathing
Parent / Guardian Names
Date of Symptom(s) Onset
If the student has symptoms, please indicate the day symptoms began.
Date of Exposure
Enter the last day the student was exposed to someone who was COVID positive.
Where was the student most likely exposed?
In the home (someone living with child)
Outside the household (friends or relatives not living with child)
In class (received close contact quarantine call from school)
On the bus (received close contact quarantine call from school)
At lunch (received close contact quarantine call from school)
School-sponsored athletics (received close contact quarantine call from school)
School-sponsored performing arts activity (received close contact quarantine call from school)
Other school-sponsored activity (clubs, after-school care, etc. - received close contact quarantine call from school)
Non-School Sponsored Extra-curricular activity
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.
If there are additional details you feel are important, please do so here.
Rides a bus to school
Walks to school
Car-rider or drives to school
Does the student intend to participate in remote learning while at home?
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This form was created inside of Mason City Schools.