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Report a Positive COVID Test Result
(Only use this form to report a STUDENT or STAFF MEMBER who has tested positive for COVID 19)
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* Indicates required question
Your Child's Last Name (If Staff Member, your own last name)
*
Your answer
Your Child's First Name (If Staff Member, your own first
name)
*
Your answer
Parent/Guardian(s) First and Last Name(s); Staff put N/A
*
Your answer
Positive COVID-19 Test Lab Collection Date (this may include an in-home test):
*
MM
/
DD
/
YYYY
Lab or Location where Test was done:
*
Your answer
If your child had symptoms, (staff: if you had symptoms) when did the symptoms start? (If no symptoms, please pick today's date and state this in the comments section at the end and choose "none" in the next question)
*
MM
/
DD
/
YYYY
If there were symptoms, please place a check mark beside the symptoms your child has had.
*
Fever
Sore throat
Cough (some cause difficulty breathing)
Diarrhea
Nausea or vomiting
Abdominal/stomach pain
Headache (possibly severe)
New loss of taste or smell
Runny nose
Congestion
Chills
Muscle pain
Shortness of breath
Repeated shaking with chills
Tiredness
Rash
Muscle Aches
Weakness
My Child Did NOT have any symptoms
Other
No Symptoms
Required
If you marked "Other" above, please explain the symptoms.
Your answer
Child's Grade Level or Staff Member
*
Preschool
Kindergarten Prep
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Staff Member
Child's or Staff Member's Home Street Address
*
Your answer
Child's or Staff Member's Home City Address
*
Your answer
Child's or Staff Member's Home State Address
*
Your answer
Child's or Staff Member's Home ZIP Code
*
Your answer
Child's or Staff Member's Birth Date
*
MM
/
DD
/
YYYY
Best Contact Phone Number (and name of the person at this number)
*
Your answer
Best Contact Email Address (and name of the person at this address)
*
Your answer
Please check mark other activities your child (or "you" if a Staff Member) is involved in at school.
*
Before Care/After Care
Athletics
Other
No Other Activities
Required
If you checked "Other" above, please list the activities your child (or if a Staff Member, "You")
recently participated in.
Your answer
What was the last day this student or staff member was in school or at a school-related activity?
*
MM
/
DD
/
YYYY
Does this child or staff member ride with other children or staff members to or from school?
*
Yes
No
If you answered "Yes" to the question above, name any other students or staff who rode in the same car with the positive student/staff member and the last date they rode together:
Your answer
Any other information you would like to share that may help us. (If not, please write "N/A")
*
Your answer
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