KSD (Student) Initial COVID-19 Exposure Interview
Name of Student *
This student has: *
Student Date of Birth *
Student Best Contact Number: *
The school of the COVID-Positive or Potential COVID Positive Student *
If the student has been tested, when did they take the test?
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If the student has been tested, where were they tested? (Facility name and location)
Did the student test positive (yes or no)
Clear selection
What are the student's symptoms and what date did each symptom start? *
If the student was exposed to a person who is COVID-positive when were they last with the COVID-positive person? *
How long was the student with the COVID-positive person? (check all that apply) *
Required
Does the student live with anyone who is COVID-positive? *
When was the student notified that the person tested positive? *
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Provide the names the student came into contact with from the time the student felt symptoms/was potentially exposed/tested positive. *
How long was the student in contact with each person named? *
Name the exact location each contact took place. *
How close was each contact? *
Was either party unmasked? *
"Close Contact" is defined as being closer than 6 feet from someone(s), for more than 15 minutes (consecutive or cumulative over 24 hours). Given this definition, name any close contacts. *
Name each and every location the student visited while on campus, even if just passing through a hallway or a building. This includes outdoor spaces, vehicles, buses, etc. *
Does the student ride a bus to and/or from school? *
If YES to riding a bus, last date student rode bus
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Does the student participate in any before or after activities (including sports)? If so, name each activity/sport? *
Is student part of an entire classroom quarantine? *
Date quarantine started
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Name of person completing form *
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