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Obama Academy 23-24 Covid-19 Reporting Form
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* Indicates required question
Date
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MM
/
DD
/
YYYY
Student Name (LAST, FIRST)
*
Your answer
Parent/ Guardian Name (LAST, FIRST)
*
Your answer
Parent/ Guardian Phone Number
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Your answer
Student Grade
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06
07
08
09
10
11
12
Last day student was in the building
*
MM
/
DD
/
YYYY
Student Vaccination Status
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Fully Vaccinated
Not Vaccinated
Day symptoms started. (If no symptoms, type "no symptoms" below)
*
Your answer
Case Type
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Positive Test
Direct Exposure to person with Covid 19
Other:
Any siblings/ relatives that work for, or attend, Pittsburgh Public Schools that live in your household? If so, list their name(s) and school(s). If none, type "none" below.
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Your answer
Day of test
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MM
/
DD
/
YYYY
Type of Test
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At home test
Medical facility or lab test
None
Results of test
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Waiting for results
Positive
Negative
No test taken
List the names of anyone with whom the student has had close contact. Close contact is defined as people you were around for 15 minutes or more without your mask and less than 3 feet apart. If none, type the word "none" below.
*
Your answer
Students should access their work via Schoology. The nurse, or administration will inform you of your return to school date. Ms. Brueckner will adjust attendance accordingly. Please email test results to
dbeaumont1@phschools.org
*
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