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EXPOSURE to COVID-19 Poff Elementary School
Please complete this form if your student was exposed to someone who is positive for COVID-19. A COVID-19 exposure is being within 6 feet of a positive person for 15+ minutes outside of school.
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* Indicates required question
Name of Person Completing Form
*
Your answer
Phone Number
*
Your answer
Parent email address
*
Your answer
Student's First Name
*
Your answer
Last's Last Name
*
Your answer
Grade
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Kindergarten
1
2
3
4
5
Date student was last in the school building
*
MM
/
DD
/
YYYY
Date of Exposure (Considered Day 0)
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MM
/
DD
/
YYYY
Is the individual who is positive in your household?
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Yes (see next question)
No
If you answered yes to the question above, is the individual who tested positive able to isolate?
Yes
No-This person's day 5 is your exposed child's day 0
Clear selection
Is your child exhibiting symptoms of COVID-19?
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Yes
No
Siblings that were exposed; Name and Grade (if any)
Your answer
Date of scheduled COVID test - if known
MM
/
DD
/
YYYY
Has your student tested positive for COVID-19 within the past 90 days?
Yes
No
Clear selection
Is your student fully vaccinated (at least 2 weeks since second dose)?
*
Yes
No
I do not wish to disclose
Not Applicable
If your student is vaccinated, what is the date of their last dose?
MM
/
DD
/
YYYY
Thank you for completing this form. Have your student stay home from school until we contact you with a return date.
*
I understand that it may take up to one day for someone to contact me.
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