COVID-19 Reporting Form
This survey provided by the nurses and will only be available to be read by nursing staff.
Are you a:
Parent of a student
Name of Student or employee:
School or Building
Did you have symptoms? If yes check all that apply below. If No symptoms skip this question.
Fever 100.4 or greater
New loss of Taste or Smell
Shortness of Breath / Difficulty Breathing
Muscle/Body aches or extreme tiredness
DIarrhea, nausea, or vomiting
What day did symptoms start? If you have no symptoms skip this question.
Are you a close contact of someone who tested positive for COVID?
Have you had a POSTIVE test for COVID?
What was the date of your test?
Are there family members who attend school or work in the district in the same building or in a different building? Please list their name and school.
If you have questions would you like a nurse to call you?
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This form was created inside of Manitowoc Public School District.