MSSD Symptom Tracker Intake Form
This form is to be used only for students or staff absent due to unexplained or unexpected illness. If you are experiencing any symptoms, you must stay home and wait to be contacted by the school district.
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Student/Staff Name *
This form is being completed for a: *
Student/Staff School *
Grade *
Who is filling out this form? *
Best way for the school to contact you (phone number or email address) *
When was the last day your child attended school? If you are a staff member, what is the last day you were at work? *
MM
/
DD
/
YYYY
Student/Staff has a CRITICAL Symptom *
Required
Student/Staff has MAJOR Symptoms *
Required
If a student/staff has a fever, what was their temperature?
Have the MAJOR symptoms resolved in 24 hours? *
Student/Staff has MINOR Symptoms *
Required
Have the MINOR symptoms resolved in 48 hours? *
IF YOU HAVE ANY SYMPTOMS, DO NOT COME TO SCHOOL/WORK UNTIL YOU HAVE BEEN CONTACTED BY SOMEONE FROM THE SCHOOL DISTRICT.
What day did the symptoms begin? Or what day were you exposed? *
MM
/
DD
/
YYYY
What time did the symptoms begin? Or what time were you exposed? *
Time
:
Has the student/staff seen a doctor for this illness? *
Has the student/staff been exposed to someone with COVID-19? *
Has the student/staff been exposed to someone who has been under quarantine for possible exposure to COVID-19 and is also symptomatic? *
Has the student/staff been tested for COVID-19? *
List any individual who has been in close contact with you outside of school AND that attends school/work in MSSD (for example, siblings, children, parents, friends) *
List any extra-curricular activities your student participates in. *
Does your student ride the bus to/from school? *
Is there additional information that you think would be helpful for our COVID Response Team to know? *
You may be contacted by someone from the district's COVID Response Team. If any symptoms or circumstances change, please email healthteam@mssd14.org. This email is being monitored, but you may not receive an immediate response. Thank your for your partnership in keeping our schools open!
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