SCISD COVID-19 Self-Reporting Form

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This form is to report an individual diagnosed with COVID-19. Spring Creek ISD will treat this information as confidential to the fullest extent allowed by state and federal law.

PLEASE NOTE: Spring Creek ISD is obligated to notify health officials if you have tested positive for COVID-19.

Email *

FIRST NAME of person completing this form *

LAST NAME of person completing this form *

Person who is experiencing COVID-19 symptoms OR has a positive test OR exposure *

is YOU

is SOMEONE ELSE

FIRST NAME of Person Experiencing COVID-19 symptoms OR has a positive test OR exposure *

LAST NAME of Person Experiencing COVID-19 symptoms OR has a positive test OR exposure *

What is the role of the person who is diagnosed or tested positive for COVID-19? *

Student

Teacher/Staff

Other

EMAIL ADDRESS of reporting person *

PHONE NUMBER of reporting person *

FOR SCISD STUDENT OR EMPLOYEE: Have you been diagnosed with a positive COVID-19 test or received a clinical diagnosis from a physician? The COVID-19 test includes rapid tests, lab tests, and home tests. *

Yes

FOR SCISD STUDENT OR EMPLOYEE: Have you had close contact with someone with a confirmed case of COVID-19? *

Yes

FOR SCISD STUDENT OR EMPLOYEE: Have you been at the Spring Creek School campus since you tested positive for COVID-19? *

Yes

FOR SCISD STUDENT OR EMPLOYEE: Have you received a COVID-19 vaccination?

Yes

Clear selection

FOR SCISD STUDENT OR EMPLOYEE: When was the last time you were on campus? *

YYYY

FOR SCISD STUDENT OR EMPLOYEE: Are you currently experiencing any COVID-19 symptoms? *

Yes

Is there any other information that you believe we need to know?

Send me a copy of my responses.

Submit

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