ESHS Parent/Guardian Covid 19 Reporting Form
Elizabeth Seton High School is committed to maintaining a healthy and safe learning and
working environment for all of our students and staff. The school administration is closely
monitoring the global public health emergency related to Covid-19 through trusted authorities
including the Center for Disease Control and Prevention (CDC) and the World Health
Organization.
This reporting form is for parents or guardians to voluntarily notify the school of information
related to exposure to or diagnosis of COVID-19 regarding their daughter. Information disclosed
in this form will be maintained as confidential and used solely to support the school’s safety
efforts and contact tracing in the context of the COVID-19 public health emergency. This
submission is not a substitute for medical advice. If your daughter experiences any COVID-related symptoms or any medical concerns, please seek medical attention immediately.
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Full Name of Student *
Student ID Number *
Date of Birth *
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Parent/Guardian Name *
Parent/Guardian Preferred Phone Number *
Parent/Guardian Preferred Email Address *
I am reporting one or more of the following:
My daughter is experiencing symptoms of Covid-19.  Date symptoms first noticed:
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My daughter has been advised by a health care provider to self-quarantine.  Dates for quarantine (please provide beginning and end dates):
My daughter tested positive for Covid-19.  Date of test:
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My daughter has been in contact with someone who has confirmed positive testing of Covid-19.  Date of potential exposure:
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Please provide any additional information related to your daughter’s exposure or contact that you think may be relevant:
I acknowledge the following (please check both): *
Required
Contact/Tracing Consent:         Effective contact tracing is one of the most beneficial actions in stopping the transmission of the virus.  Thus, the ability to identify and inform people of their close contact with possible or confirmed COVID-19 exposure is an extremely helpful measure in stopping the spread of the disease.  The CDC defines “close contact” as being within six feet of a person for a extended period (15 minutes or greater).  School personnel will contact you for permission prior to identifying your daughter by name during any contact tracing efforts.
Please indicate the last date your daughter was in contact with anyone at Elizabeth Seton High School:
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Aside from your daughter’s classes, please identify any student or staff member who your daughter may have been in close contact with within the 14 days prior to your daughter’s first experienced symptoms or the date of her test:
Please provide any additional information related to your daughter’s contacts that you think may be relevant:  
At the conclusion of the 14-day quarantine period, please forward your daughter’s doctor clearance to return to school to one of the following people:  schoolnurse@setonhs.org (nurse)  ehagar@setonhs.org (president)
All documents will remain confidential and not part of your daughter’s student records.
Signature of Parent/Guardian *
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