Student COVID Reporting Form
Please provide the information below for the student impacted by COVID-19.
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Last Name of Individual Completing this Form *
First Name of Individual Completing this Form *
Individual Completing this Form's Relationship with the student: *
Required
Individual Completing this Form's Phone Number *
Student's Last Name *
Student's First Name *
Student's School *
Student's Grade *
Student's last date on District property (FORMAT: 06/01/21). *
Phone number of student/parent/guardian. If unknown, enter NA. *
Is the student experiencing symptoms consistent with COVID-19? *
Required
If yes, please enter date of symptoms onset. If no, enter NA. (FORMAT: 06/01/21)
Has the student been tested for COVID-19? *
Required
If yes, please enter date of testing. If no, enter NA. (FORMAT: 06/01/21)
Please specify student's status: *
If your student tested positive for COVID, was the test lab confirmed (antigen or PCR) or confirmed using an over the counter home test (ex BinaxNow)?
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