Student Reporting Form for COVID-19 (outside of school day hours)
This questionnaire asks about student health and potential exposure to COVID-19. The data collected may be classified as private under the MN Government Data Practices Act. The data you share may be used for the following purposes:

1.) To screen for potential COVID-19 related symptoms and exposures in an effort to avoid the spread of COVID-19
2.) To determine when it is safe for the student to return to school;
3.) If the student has tested positive for COVID-19, the information shared may also be used to notify other individuals who may have been exposed to COVID-19 through their contact with the student. If this is the case, the student’s name will not be used with these individuals.

You are not legally required to provide this data. However, if you decline to provide the information requested, the student may not be admitted into the school. Data collected may be shared with school district staff, and other persons or entities authorized by law, including public health authorities. De-identified data may also be used with individuals who may have been exposed to COVID-19 through their contact with the student.
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Email *
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Name(s) *
Phone Number *
My child has the following symptoms of Covid 19 *
Required
Symptoms first appeared on what day? *
MM
/
DD
/
YYYY
My child has received a positive test result for COVID-19 *
Please list any additional family members that attend a school in District 196 (provide name and school):
Please list any sport or activity your child participates in:
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