Reporting Student and MPS Staff At-Home Positive Rapid Antigen Results
Please complete this form for each positive student or MPS staff member you are reporting.

We understand how difficult it is at this point to get a PCR test.

If your at-home rapid antigen test is positive, we encourage you to get a second confirmation with a PCR test if possible. If your positive antigen test was confirmed by a PCR test, this data is automatically shared with the Melrose Health Department and you do not need to do anything further.

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First name of person completing this form? *
Last name of person completing this form? *
First name of student or MPS staff member who tested positive for COVID-19? *
Last name of  student or MPS staff member who tested positive for COVID-19? *
Role of  student or MPS staff member who tested positive for COVID-19? *
Was this positive result was collected using an iHealth test kit provided my MPS? *
What school does the positive individual attend? *
Does this individual have siblings in other schools? If yes, please name the school. *
Vaccination status of positive individual?
One dose
Two doses
Third dose
Not vaccinated
Moderna
Pfizer
J&J
Not vaccinated
Date of last vaccine? *
MM
/
DD
/
YYYY
Date of symptom onset? *
MM
/
DD
/
YYYY
Date of positive test? *
MM
/
DD
/
YYYY
Other information you would like to share about this positive COVID-19 case:
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