COVID-19 Reporting Form
This survey provided by the nurses and will only be available to be read by nursing staff.
Are you a: *
Required
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.
What day did symptoms start? If you have no symptoms skip this question. *
MM
/
DD
/
YYYY
Are you a close contact of someone who tested positive for COVID?
Clear selection
Have you had a POSTIVE test for COVID?
Clear selection
What was the date of your test?
MM
/
DD
/
YYYY
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?
Submit
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