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Millersburg Area School District Positive COVID-19 Test Result Reporting Form
Please use the link above to report if your student has received a positive test result for COVID-19. We will contact you the next business day with further instructions.
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* Indicates required question
Email
*
Your email
Parent First Name
Your answer
Parent Last Name
Your answer
Parent Phone Number
Your answer
Student First Name
Your answer
Student Last Name
Your answer
Student Date of Birth
MM
/
DD
/
YYYY
Student Home Address
Your answer
Student Grade Level
Choose
K
1
2
3
4
5
6
7
8
9
10
11
12
Names and Grades of Siblings
Your answer
Date of Symptom Onset
MM
/
DD
/
YYYY
Description of Symptoms
Your answer
Last Date in School
MM
/
DD
/
YYYY
Notes Regarding When Student Last Attended School (ex. sent home early, classes not attended, etc., anything to help contact tracing)
Your answer
Date COVID Test Taken
MM
/
DD
/
YYYY
Date Positive Test Results Received
MM
/
DD
/
YYYY
Name of Home Test or Testing Site
Your answer
Does The Student Ride The Bus?
Yes
No
Clear selection
Extracurricular Activities
Your answer
Names of Students The Positive Case Rode To Or From School With (more than 15 minutes)
Your answer
Lunch Contacts 2 Days Prior To, Or Anytime After Symptom Onset (Students are now separated at lunch. This question is no longer applicable. Please skip to the next question.)
Your answer
Parent Has A Return To School Note For Student
Yes
No
Will Get One From Primary Care Physician
Clear selection
If The Parent Has Return To School Note, Has It Been Sent To The School?
Yes
No
N/A
Clear selection
If Yes, Who Was The Note Sent To?
Your answer
Any Additional Notes Or Comments
Your answer
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