Student Positive Self-Report
Use this form if you are a parent or student enrolled in Jeffco Public Schools. If you are a student under 18 years of age, this form requires the approval of a parent/guardian to submit. Participation will help the district track incidence of COVID-19 during periods of remote learning. You may also directly contact your school nurse.
Student ID
Student First Name *
Student Last Name *
Parent/Guardian Full Name
Parent/Guardian Preferred Contact Telephone Number
Parent/Guardian Preferred Email
In which school is your student currently enrolled? *
If the student is enrolled in more than one school please select the students primary school of enrollment.
Students Current Grade Level *
Student Test Date *
MM
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DD
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YYYY
Date you Received Students Test Results *
MM
/
DD
/
YYYY
Submit
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