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COVID-19 Positive Student Form
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* Indicates required question
Parent/Guardian Email Address
*
Your answer
Student First Name
*
Your answer
Student Last Name
*
Your answer
Grade
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian Full Name
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Mailing Address
Your answer
Is student experiencing symptoms?
*
Yes
No
First date of symptoms, if experiencing.
MM
/
DD
/
YYYY
Date student was last on campus.
*
MM
/
DD
/
YYYY
Date Tested
*
MM
/
DD
/
YYYY
Testing Site Name
Arkansas Children's Hospital
Baptist Hospital
Baptist Urgent Care
Med Express Urgent Care
Natural State Laboratory
UAMS
Infinite Genomics Lab
Home Test
Other:
Clear selection
Testing Site Location (City)
Your answer
What type of test was completed?
Nasal PCR
Rapid PCR
Rapid Antigen
Throat Swab
Clear selection
Date test results were reported.
*
MM
/
DD
/
YYYY
Please choose all school activities in which the student participates.
*
After School Extra Class
Basketball
Cheer
Club meeting, during x-period, lunch, or after school
Cross Country
Dance
Extended Day
Football
Lacrosse
Soccer
Swimming
Tennis
Volleyball
Wrestling
None
Other:
Required
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