Self Reporting of Positive COVID-19 Cases
Please complete this form if your child has received Positive COVID-19 test results from the doctor or another testing location. Someone from the school district will follow up with you. We appreciate you sharing this information so that we can identify close contacts in the school and continue keeping students and staff safe.

Please make sure that your child stays home from school and any other activities until their isolation period ends. The school nurse or another district official will be in contact to discuss returning to school.
Sign in to Google to save your progress. Learn more
Student's First Name *
Student's Last Name *
Student's Grade *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Address *
Parent/Guardian Name *
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
Date Tested for COIVD-19 *
MM
/
DD
/
YYYY
Where was your child tested? *
What symptoms does your child have? *
When did the symptoms start? *
MM
/
DD
/
YYYY
How does your child get to school? *
Required
How does your child get home from school? *
Required
Please list any sports, clubs, or extracurricular activities your child participates in while at school.
Please list any other children who live in the home or that the child has been around two days before they started feeling bad or were tested?
Any other information that you would like for us to know ?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms