Covid-19 Self-Reporting Form (Palm Beach Gardens Campus)

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This form is to be used by Franklin Academy staff, parents, students, vendors, volunteers and other community members. Self-isolation would be associated with exposure to someone with actual COVID-19 or having a positive test result. This information is needed to provide support to you or a student under your care, during self-isolation and to monitor the potential presence of COVID-19 in the schools. This information will not be used for any punitive or other negative consequences.

You will receive customized questions after indicating the person's role at Franklin. Thank you for completing this form.

Responses to this survey are considered educational records with regards to students and employment records with regards to employees and are subject to all applicable privacy statutes, regulations and guidance including FERPA, IDEA and HIPPA.

Email *

What is your full name? *

What is the full name of the person testing positive or exposed to Covid19, if different than above?

What phone number can be used to contact you? *

For what reason did you begin self-reporting? *

Positive test result for COVID-19

Exposure to someone with positive test result for COVID-19

On what date was the positive test result received or the date of the exposure you are reporting? *

YYYY

Please indicate the primary role of the person testing positive for Covid-19 or exposed to Covid-19? *

Parent

Staff

Student

Vendor

Volunteer

Other

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