COVID-19 Intake Form

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Staff or Students who are staying home due to symptoms, concerns, or diagnoses of COVID-19 and have been exposed to COVID-19 should complete this confidential health and safety intake form.

Email *

Last name, First name *

If entering on behalf of someone else please add their name here

Email *

Of person completing form

Best Phone Number to Contact You *

Type

WPS Staff

WPS Student, Parent Reporting

WPS Student, Self Reporting

Other:

Clear selection

School *

Westwood Integrated Preschool

Deerfield Elementary

Downey Elementary

Hanlon Elementary

Martha Jones Elementary

Sheehan Elementary

Thurston Middle School

Westwood High School

Central Office

Grade Level (enter grade level for student or type "staff")

Vaccination Status

In general, people are considered fully vaccinated: ±2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine. If you don’t meet these requirements, regardless of your age, you are NOT fully vaccinated.

Fully vaccinated and Boosted

Completed the primary series of Pfizer or Moderna vaccine within the last 6 months

Completed the primary series of J&J vaccine within the last 2 months

Completed the primary series of Pfizer or Moderna vaccine over 6 months ago and are not boosted

Completed the primary series of J&J over 2 months ago and are not boosted

Incomplete Primary series of Pfizer or Moderna vaccine

Unvaccinated

Other:

Clear selection

Have you/student tested positive for COVID-19? *

If No, proceed with Onset of Symptoms, 3 questions below. If Yes, proceed with all remaining questions.

Yes

Required

Date of Positive COVID-19 Test

Do not come to school if reporting a positive COVID-19 test in last 6 days.

YYYY

Test Type

Rapid Antigen (at Home)

Rapid Antigen (by Provider)

PCR

Other:

Onset of Symptoms

Fever (100.0° Fahrenheit or higher), chills, or shaking chills - Difficulty breathing or shortness of breath• New loss of taste or smell• Muscle aches or body aches• Cough (not due to other known cause, such as chronic cough)• Sore throat, when in combination with other symptoms• Nausea, vomiting, or diarrhea when in combination with other symptoms• Headache when in combination with other symptoms• Fatigue, when in combination with other symptoms• Nasal congestion or runny nose (not due to other known causes, such as allergies) when in combination with other symptoms

YYYY

Define Symptoms

Fever (100.0° Fahrenheit or higher)

Fever (<100.0° Fahrenheit)

Chills, or shaking chills

Difficulty breathing or shortness of breath

New loss of taste or smell

Muscle aches or body aches

Cough

Sore throat

Nausea, vomiting, or diarrhea

Headache

Fatigue

Nasal congestion or runny nose (not due to other known causes, such as allergies)

Other:

If you/student play(s) a High School sport, please indicate the sport(s) below

Are any other household members affected?

Yes

Please briefly describe your situation

Submit

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