Student Reporting Form for COVID-19 (outside of school day hours)
Please complete this form if it is outside of the school day or during the weekend, and you suspect that your child has COVID-19 or he/she has a confirmed case of COVID-19.

If it is during the school day and you suspect that your child has COVID-19 or he/she has a confirmed case of COVID-19, please call our school at (651) 423-7501 and ask to speak to our school nurse.
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Data Privacy Statement
This questionnaire asks about student health and potential exposure to COVID-19. The data collected may be classified as private under the MN Government Data Practices Act. The data you share may be used for the following purposes:

1.) To screen for potential COVID-19 related symptoms and exposures in an effort to avoid the spread of COVID-19;
2.) To determine when it is safe for the student to return to school;
3.) If the student has tested positive for COVID-19, the information shared may also be used to notify other individuals who may have been exposed to COVID-19 through their contact with the student. If this is the case, the student’s name will not be used with these individuals.

You are not legally required to provide this data. However, if you decline to provide the information requested, the student may not be admitted into the school. Data collected may be shared with school district staff, and other persons or entities authorized by law, including public health authorities. De-identified data may also be used with individuals who may have been exposed to COVID-19 through their contact with the student.
Student Last Name *
Student First Name *
Student Date of Birth *
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Parent/Guardian Name(s) *
Best Phone Number to reach parent *
Student's teacher *
Has anyone in your household had a positive COVID-19 test recently? *
My Child has the following More Common Symptoms of COVID-19 (check all that apply)
My Child has the following Less Common Symptoms of Covid 19 (check all that apply)
Symptoms first appeared on what day?
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My child has received a positive test result for COVID-19 *
Please list any additional family members that attend a school in District 196 (provide name and school):
Does your child participate in SACC (School Aged Child Care) at Greenleaf? *
Does your child take the bus to and from school? *
What is your child's bus number?
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