IHSNO Students COVID-19 Worksheet
COVID-19 Worksheet
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Email *
Date *
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Student's name (Last name, First name) *
Is the student Vaccinated *
Has the student received laboratory testing for COVID-19? *
If yes, what was the result? *
If yes, what kind of test was performed? (Note: this information might be included as part of the laboratory test results and/or in a letter sent with the test results. Molecular/viral tests are generally conducted on a swab sample collected from the respiratory system (such as the nose or mouth). Antibody tests are generally conducted on a  sample of blood.) *
Does the student have any of the following symptoms? (choose all that apply) *
Required
When did the first symptom begin or when was the student exposed to someone who tested positive for COVID-19? *
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Is the student or school worker a close contact of another person with COVID-19 at this school? If yes, please provide the name and phone number of this person (if known) *
Is the student a close contact of a person with COVID-19 not associated with IHSNO? (Note: this would include any person in the student’s household or with whom the student has had close contact (close contact for COVID-19 is defined as being within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hr period) who is NOT another student/faculty/staff of the school.) *
Parent/guardian name (Last name, First name). *
Parent/guardian phone number (xxx) xxx-xxxx *
Parish that the student resides in: *
Student's grade: *
Student's date of birth *
Student's gender *
Student's ethnicity *
Student's race *
Student's race *
Email *
Phone number *
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