CCPS Over the Counter Covid Test Assurance Form
This form is to be filled out for a student or staff member who is needing to complete a Covid Home test. This form will need to be filled out for symptomatic , surveillance, or individuals who have had a close contact.

Testing for symptomatic individuals should be given at 24 hours and 48 hours from when symptoms began.

Testing for individuals who have been a close contact with a positive individual will need to test three times. The last day being day 5, unless living with a confirmed positive( if so you will need to test an additional 3 times for a 10 day period) from last contact with a Covid positive individual.

Testing for individuals for surveillance will be one test per week.

Individuals should stay home if they are symptomatic and notify the school nurse.

This document assures that the test was completed with accuracy and that results were read appropriately.
Individuals Full Name *
Who is being tested? *
Name of Covid Home test *
Date of first test ( only need one if test is for surveillance testing) *
Result of first test
Date of second test
Result of second test
Date of third test
Result of third test
I attest that I have self-administered the rapid antigen test indicated above. All test-specific instructions were followed and completed correctly. I have viewed and verified the results. Please write parent/guardian full name. *
ส่ง
ล้างแบบฟอร์ม
ห้ามส่งรหัสผ่านใน Google ฟอร์ม
แบบฟอร์มนี้ถูกสร้างขึ้นภายใน Cottonwoodclassical.org รายงานการละเมิด
Google ฟอร์ม