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2022/2023 School Year Positive Covid19 Case Report
To report a positive case of Covid19, please fill out the form below. If you need assistance with completing this form or reporting a case in general please email or call the following covid support staff: (Madison Wells /
mwells@upsd83.org
)
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* Indicates required question
Email
*
Your email
Student/Staff First & Last Name
*
Your answer
Student/Staff Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian Full Name (staff put N/A)
*
Your answer
Contact Phone Number
*
Your answer
Date of Covid Test
*
MM
/
DD
/
YYYY
Type of test taken
*
iHealth rapid test
Lets Get Checked (PCR home test)
Everlywell (PCR home test)
Other rapid antigen or point of care test
other PCR/NAAT based test
Symptom Onset Date (use test date, if no symptoms)
*
MM
/
DD
/
YYYY
Number of Covid-19 Vaccination Doses
*
Fully Vaccinated (1 or 2 doses per manufacturer recommendations)
Fully Vaccinated with booster(s)
Partial Vaccination (1 dose)
None
Prefer not to answer
School / Building
*
Your answer
Date last in school / building
*
MM
/
DD
/
YYYY
Grade Level or Work Site
*
Your answer
List of School Sponsored Extra-Curricular Activities (school clubs, sports, performing arts, etc.)
*
Your answer
Any known exposure to a positive case of covid, if so where (family, event, travel, etc)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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