Millersburg Area School District Positive COVID-19 Test Result Reporting Form
Please use the link above to report if your student has received a positive test result for COVID-19. We will contact you the next business day with further instructions.
Email *
Parent First Name
Parent Last Name
Parent Phone Number
Student First Name
Student Last Name
Student Date of Birth
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Student Home Address
Student Grade Level
Names and Grades of Siblings
Date of Symptom Onset
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Description of Symptoms
Last Date in School
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Notes Regarding When Student Last Attended School (ex. sent home early, classes not attended, etc., anything to help contact tracing)
Date COVID Test Taken
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Date Positive Test Results Received
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YYYY
Name of Home Test or Testing Site
Does The Student Ride The Bus?
Clear selection
Extracurricular Activities
Names of Students The Positive Case Rode To Or From School With (more than 15 minutes)
Lunch Contacts 2 Days Prior To, Or Anytime After Symptom Onset
Parent Has A Return To School Note For Student
Clear selection
If The Parent Has Return To School Note, Has It Been Sent To The School?
Clear selection
If Yes, Who Was The Note Sent To?
Any Additional Notes Or Comments
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