COVID-19 Reporting Form

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Please use this form to report any student or staff member:

1) who is experiencing symptoms of COVID-19,
2) who has received a diagnosis of COVID-19 confirmed by a test or
3) who has been in close contact with a person who has a positive COVID-19 test.

If this report is regarding a student, please complete a form for each student in the home.

A campus nurse or the MISD Director of Health Services may follow up on this report to gather more details or to provide instructions.

First and last name of student or staff member this report is about: *

Who should be contacted if MISD has questions about this report? Please include name and phone number. *

The subject of this report is a: *

Student

Staff member

Not applicable

Name of School Campus or District Building *

Grade Level (if a student)

Face to Face or Virtual Learner? *

Face to Face

Virtual Learner

Virtual Learner with On-Campus Activities

This subject of this report is not a student.

Does the subject of this report live in the same home as someone who has tested positive for COVID-19? *

Yes

Has the subject of this report been in close contact with someone who has tested positive for COVID-19? *

Yes

Unsure

If you answered yes to the previous question, describe the circumstances and when the close contact occurred. *

Is the subject of this report currently experiencing COVID symptoms? *

Yes

If you answered yes to the previous question, when did the symptoms begin?

YYYY

Has the subject of this report received a COVID-19 vaccine? *

Yes

I prefer not to answer.

Select all symptoms the subject is experiencing:

not experiencing symptoms

fever or chills

cough

shortness of breath or difficulty breathing

fatigue

muscle or body aches

headache

new loss of taste or smell

sore throat

congestion or runny nose

nausea or vomiting

diarrhea

Date of COVID test, if taken

YYYY

Result of COVID Test *

Positive

Negative

Did not have a test.

Waiting on test results

Has the subject of this report been told to quarantine by a medical professional? *

Yes

What date will the quarantine period end, if applicable?

YYYY

Is there any additional information you would like to provide?

Submit

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