FCCPS Staff/Student Covid-19 Positive Case or Exposure Reporting Form
Dear Parent/Guardian or Staff Member,

Thank you for reaching out for support. In order to expedite assistance and communication, please fill out this form for each positive COVID-19 case or exposure you need to report. This information will be evaluated by our FCCPS Health Team and staff who will contact you regarding next steps for returning to school/work.  

If you are a reporting a student positive case someone from the school will be contacting you regarding streaming/remote instruction.  Please remember to report your child absent to your schools attendance line.

FCCPS follows the CDC, VDH's, and the FCHD's latest guidance regarding positive cases and exposures. This will help us determine a return to in person learning date and facilitate the contact tracing process.

We appreciate your cooperation and support as we all work together to keep our learning community healthy.

Fondly,
Rebecca Sharp, Executive Director of Special Services


Sign in to Google to save your progress. Learn more
Email *
What type of concern are you reporting? *
First Name of Positive Case or Exposed Person (Staff/Student) *
Last Name of Positive Case or Exposed Person  (Staff/Student) *
Date of Birth of Case/Exposed Person *
MM
/
DD
/
YYYY
Parent/Guardian Name (if applicable)
Parent/Guardian or Staff Phone Number *
School or  Primary Work Location *
What grade is your student in?
Clear selection
If grade Pre-K through 5th, please list Teacher
If staff, please list Job Title
Last date of attendance at school/work or any FCCPS sports/activities. *
MM
/
DD
/
YYYY
Does your student attend FCCPS Day Care? *
First day symptoms started (if applicable)?
MM
/
DD
/
YYYY
Please identify any symptoms that you have experienced. *
Required
Date of COVID test?
MM
/
DD
/
YYYY
Are you or your student up to date on Covid-19 vaccinations?  (2 weeks after second shot or booster, if eligible--please note the booster requirement to be considered fully vaccinated is only applicable to those 12 years and older)  Please upload your/your student's vaccine card to https://fccps.qualtrics.com/jfe/form/SV_4MFakGDYMa3Xsr4, if you haven't already. Staff should upload their most recent form to:  FCCPS Staff Vaccination Card Repository. *
Please list any other students or employees who reside in the household with the positive case, if applicable, and their vaccination status.
Please share anything else you wish for the health team to know regarding this positive case or exposure situation.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Falls Church City Public Schools. Report Abuse