COVID-19 Positive Case Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If a student or a staff member tests positive for COVID-19, please complete this questionnaire to the best of your ability. This will assist us with the contact tracing process. You will be contacted regarding the return to school date based upon completion of the 5-day quarantine. Thank you!

For K-5 students: anticipate information about a return to school date and how to connect to the Remote Classroom.

For 6-8 and 9-12 students: anticipate connecting with your teachers via Google Classroom.

Email *

School/Building *

Please select one: *

Student

Staff Member

Last Name *

First Name *

Date of Birth *

YYYY

Home Address *

Parent/Guardian Name(s) - For Students Only

Home Phone *

Mobile Phone *

Household Close Contacts *

Is the student/staff member fully vaccinated? *

Yes

Has the student/staff member been exposed to anyone that has tested positive? *

Yes

Please provide the date when symptoms started.

YYYY

If no symptoms, please provide the date tested.

YYYY

Which test was administered? *

Rapid Test

PCR Test

At-home Test

Is everyone in your household fully vaccinated?

Yes

Clear selection

Please list any close contacts (i.e. family, friends).

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Ridgewood Public Schools. Report Abuse

Forms