COVID-19 Staff/Student Self Reporting Form
Complete the form below to make a COVID-19 report to Polk County Schools.
Location *
I am completing this form because: *
Required
If you have been in direct contact with a COVID-19 positive person, when was the estimated date of exposure? (If this doesn't apply to you, please leave it blank)
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If you have symptoms of COVID-19, when did you develop noticeable symptoms? (If this doesn't apply to you, please leave it blank)
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DD
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If you have been tested, when was the date of test? (If this doesn't apply to you, please leave it blank)
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If you have been tested and it was not with the health department, where did you test? (This will help expedite the tracing process).
If you have been tested and received the result, was it positive?
Clear selection
I am a: *
First Name: *
Last Name: *
Last four digits of social security number. *
Your email if you have one.
Your phone number. *
Do you have any additional information about your report you would like to mention?
Submit
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