Union City Area School District COVID-19 Reporting

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All information in this survey will be kept confidential. The purpose of this information is to provide the district with as accurate information as possible on the amount of spread of COVID-19 in our district, and to also follow up with families to see if we can support in any way as a district. Thank you in advance for your cooperation.

Please select who this report is regarding: *

Student(s)

Family member that resides in the same house

Both

Please select the grade(s) of all of your student(s) residing at your residence: *

Required

Please list the first and last name(s) of your student(s): *

Please describe your circumstances in the box below. It would be helpful if we knew which members are positive or probable and when the onset of symptoms began. Example: My son Joe Smith in second grade is COVID positive. He began to feel sick on Monday, December 7th. No other members of the family have had symptoms. *

Please list the best phone number to get in contact with you: *

Thank you for taking the time to fill out the survey. Someone from the district will be in contact soon.

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