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Report a Positive COVID Test Result
(Only use this form to report a STUDENT who has tested positive for COVID 19)
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* Indicates required question
Your Child's Last Name
*
Your answer
Your Child's First Name
*
Your answer
Parent/Guardian(s) First and Last Name(s)
*
Your answer
Positive COVID-19 Test Lab Collection Date:
*
MM
/
DD
/
YYYY
Lab or Location where Test was done:
*
Your answer
If your child had symptoms, when did the symptoms start? (If child had no symptoms, please skip)
*
MM
/
DD
/
YYYY
If there were symptoms, please place a check mark beside the symptoms your child has had.
*
Fever
Sore throat
Cough (some cause difficulty breathing)
Diarrhea
Nausea or vomiting
Abdominal/stomach pain
Headache (possibly severe)
New loss of taste or smell
Runny nose
Congestion
Chills
Muscle pain
Shortness of breath
Repeated shaking with chills
Tiredness
Rash
Muscle Aches
Weakness
My Child Did NOT have any symptoms
Other
Required
If you marked "Other" above, please explain the symptoms.
Your answer
Child's Grade Level
*
PK3
PK4
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Child's Home Street Address
*
Your answer
Child's Home City Address
*
Your answer
Child's Home State Address
*
Your answer
Child's Home ZIP Code
*
Your answer
Child's Birth Date
*
MM
/
DD
/
YYYY
Best Contact Phone Number (and name of the person at this number)
*
Your answer
Best Contact Email Address (and name of the person at this address)
*
Your answer
Please check mark other activities your child is involved in at school.
*
Before Care/After Care
Athletics
Other
No Other Activities
Required
If you checked "Other" above, please list the activities your child recently participated in.
Your answer
What was the last day this student was in school?
*
MM
/
DD
/
YYYY
Does this child ride with other children to or from school?
*
Yes
No
If you answered "Yes" to the question above, name any other students who rode in the same car with the positive student and the last date they rode together:
Your answer
Any other information you would like to share. (If not, please write "N/A")
*
Your answer
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