Family Self-Reporting

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Please use this form to self-report symptoms, positive cases of Covid-19 or required quarantine.

Student's First Name *

Student's Last Name *

Student's School *

Student's Grade *

Please select the option that best describes the situation: *

Student tested positive for Covid 19

Family member tested positive for Covid 19 so student is quarantined

Student was exposed to Covid 19 and was tested. Quarantined until results come back.

Student is experiencing symptoms

Someone in the household is experiencing symptoms and was tested, student quarantined until test results come back

Other:

If you selected other for the previous question, please explain

Please select symptoms from the list below: *

Fever or chills

Cough

Shortness of breath

Fatigue

Muscle or body aches

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

No Symptoms

Other:

Required

Who is completing this form? *

Parent/Guardian

Student

Turner School District Personnel

Other:

Best phone number and time of day to be reached by district nurse. *

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