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Covid-19 Reporting Student Isolation & Positive PCR Form
If you do not have test results back at the time of filling in this form, please email
strategic@ormistonvictoryacademy.co.uk
once you receive them along with the confirmation of your results.
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* Indicates required question
Student First Name
*
Your answer
Student Surname
*
Your answer
Parent/Carer Email Address
*
Your answer
Year Group
*
7
8
9
10
11
12
13
Year
7
8
9
10
11
12
13
Year
Who is displaying symptoms in your household?
*
Student
N/A - We are isolating due to student having a medical procedure - Evidence required
N/A - We are isolating due to someone in the household requiring a medical procedure - Evidence required
Required
Symptoms displayed
*
Temperature - over 38
New and persistent cough
Loss of taste and/or smell
N/A
Other:
Required
Date of Symptoms Onset
MM
/
DD
/
YYYY
Lateral Flow Test Completed?
Yes
No
N/A
Clear selection
Date of Lateral Flow Test
MM
/
DD
/
YYYY
Result of Lateral Flow Test
*
Positive
Negative
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