COVID-19 Winter Break Reporting
Please use this form as a method of communication with the School District over the holiday break regarding COVID-19.

Any questions or concerns regarding COVID-19, please call the Clark County Combined Health District at 937-390-5600. Any questions or concerns for the school nurse, please email Savannah Brady at sbrady@sels.us.
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Email *
Date *
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Student's First and Last Name *
Student's School *
Grade *
Homeroom Teacher(MV) or 1st Period Class(JH/HS) *
Parent/Guardian First and Last Name *
Home Address *
Phone Number *
Has the student been in close contact with a COVID-19 positive case? (Within 6 feet of the positive individual for 15 minutes or more) *
If yes, please enter the last date of contact with the positive COVID-19 case.
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Close Contact Instructions
If the student has had close contact with someone who has tested positive, the student must quarantine for 10 days from the last date of contact if the student is showing no symptoms (day 1 beginning the day after contact) through day 10. The student will be done with quarantine on day 11 if symptom free.
Has the student tested positive for COVID-19? *
When was the last day the student attended school?
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Positive Case Instructions
If a students tests positive for COVID-19, the student must isolate and household members must quarantine. If possible, please have the student use a separate bathroom from other household members. Otherwise, please disinfect high touch surfaces (i.e., toilet, light switches, door handles).


**The student’s isolation will begin from the onset of symptoms. Isolation will last for 10 days (day 1 beginning the day after symptom onset) through day 10. The student may leave isolation on day 11 if symptom free.
Has a member in your household tested positive for COVID-19? *
Name of Positive Individual(s)
Symptoms: (select all that apply) *
Required
Instructions if a Household Member Tests Positive
If a member of your household tests positive, each student in the household's quarantine will begin from the last date of contact and last for 10 days if the student is showing no symptoms (day 1 beginning the day after the last day of contact) through day 10. The student may leave quarantine on day 11 if symptom free.
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