COVID-19 Reporting Form
This survey provided by the nurses and will only be available to be read by nursing staff.
* Required
Are you a:
*
Parent of a student
Employee
Required
Name of Student or employee:
Your answer
School or Building
Your answer
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
Severe Cough
Shortness of Breath / Difficulty Breathing
Chills
Muscle/Body aches or extreme tiredness
DIarrhea, nausea, or vomiting
Sore Throat
Other
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?
Yes
No
Unsure
Clear selection
Have you had a POSTIVE test for COVID?
Yes
No
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.
Your answer
If you have questions would you like a nurse to call you?
Yes
No
Submit
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