JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Lake Shore COVID-19 Reporting
Note: This is confidential information. Please do not disclose or discuss with any other party.
Once the COVID-19 Reporting form is submitted, the COVID Support Team will review the information and will follow up and provide notification.
Fill out one form per case.
Questions around this process may be submitted to COVID Support Liaison Karen Jones (
kjones@lsps.org
) or Deputy Superintendent Dr. George Lewis (
glewis@lsps.org
).
Answer all applicable questions:
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Today's Date:
*
MM
/
DD
/
YYYY
I am reporting a COVID related incident about:
*
Myself
A student
Another LSPS Employee
Please indicate which statement best describes what you have been told about this individual:
*
A confirmed positive case of COVID
A confirmed close contact to a person with COVID (6ft, 15 min over 24 hours, mask or no mask)
A suspected close contact to a person with COVID (6ft, 15 min over 24 hours, mask or no mask)
Showing symptoms and waiting test results
Other:
If you are reporting a positive, suspected, or close contact of a STAFF MEMBER, give their name (Last, First), phone number, and building: Smith, Johnny - 586-555-1212, Kennedy Middle School
Your answer
If you are reporting a positive, suspected, or close contact of a STUDENT, give their name (Last, First), grade, building, parent name and phone number: Jones, Suzy, 1'st grade, Violet, Mrs. Jones, 586-555-1212
Your answer
Name of Person Completing Form (Last, First):
Your answer
Please provide any information that you are aware of that would helpful regarding this positive, suspected, or close contact:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lake Shore Public Schools.
Report Abuse
Forms
