ACS 22-23 COVID  Reporting Form

FAMILIES (Use this form if) :
- Your child has recently tested positive for COVID-19.
- Your child has or recently had COVID-19 symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea/vomiting, diarrhea

STAFF (Use this form if): .
-You have  tested positive for COVID-19.  
-You have or recently had COVID-19 symptoms:  fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea/vomiting, diarrhea

A COVID Coordinator will contact you within 24 hours.
**All information is confidential**
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Email *
Please select one: *
Select School/Work Site *
Student/ Staff Name (First/Last) *
Date of Birth *
Parent/Guardian Name
Phone Number (xxx-xxx-xxxx) *
Which are you reporting? (Check all that apply) *
Required
First Day of Symptom OR                                            Positive Test Result (if asymptomatic)                                                 (month/day/year) *
Last day staff/student was on campus (month/day/year) *
Would you like a COVID coordinator to call you?
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