Report Your Child as a CLOSE CONTACT
This form should only be used to report a Student who has recently been identified as a CLOSE CONTACT with a person who tested Positive for COVID-19 within two days of your child's last exposure to them.

CLOSE CONTACTS may include: a family member presently living in your home, or anyone your child spent 15 minutes or more with, within six feet of that person with COVID-19 over a period of 24 hours.

*Please fill out this form for each child affected.
**We are currently following our local Health Department Guidelines for schools that require "Close Contacts" to quarantine for 14 days from the date of their last exposure to the Positive person, unless they too become "positive," which may extend the quarantine time period.
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Your Child's Last Name *
Your Child's First Name *
Parent/Guardian(s) First and Last Name(s) *
Date of student's last exposure to person testing positive for COVID-19. *
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Is the COVID positive person living in the same household? (If "Yes," Explain whether they are being isolated from your child or not) *
Does your child currently have any signs or symptoms related to COVID-19? *
If you answered "yes" above for symptoms, please place a checkmark beside the symptoms your child has or has had recently. *
Required
If you marked "Other" above, please explain the symptoms.
Has your child been tested for COVID-19? (Yes/No and Please list the date(s) tested and results found for each date) *
Were you told by a Health Professional how long he/she would need to quarantine? And/or told what date your child could return to school? Please explain! (Please note: Queen of Angels reserves the right to make the final determination on the date of return for your child.) *
Child's Grade Level *
Child's Home Street Address *
Child's Home City Address *
Child's Home State Address *
Child's Home ZIP Code *
Child's Birth Date *
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Best Contact Phone Number (and name of the person at this number) *
Best Contact Email Address (and name of the person at this address) *
Please check mark other activities your child is involved in at school. *
Required
If you checked "Other" above, please list the activities your child recently participated in.
What was the last day this student was in school? *
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Does this child ride with other children to or from school? *
If you answered "Yes" to the question above, name any other students who rode in the same car with the positive student and the last date they rode together:
Any other information you would like to share. (If not, please write "N/A") *
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