Report Your Child (or Staff Member) as a CLOSE CONTACT
Although students and staff no longer have to quarantine as close contacts, it is important to know they have been exposed so that proper precautions and social distancing are in place in the classrooms, lunchroom, etc.

This form should only be used to report a Student or Staff Member who has recently been identified as a CLOSE CONTACT with a person who tested Positive for COVID-19 within two days of the student's or staff member's last exposure to them.

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

*Please fill out this form for each Q of A student or staff member in your household considered to be a close contact.
**We are continuing to follow our local Health Department Guidelines for schools that recommends "Close Contacts" MASK for 10 days from the date of their last exposure to the Positive person, close contacts should get tested on day 5 and if they become "positive," the isolation and quarantine time period may be extended.
Sign in to Google to save your progress. Learn more
Student's or Staff Member's Last Name *
Student's or Staff Member's First Name *
Parent/Guardian(s) First and Last Name(s) (if Staff Member, write, "self") *
Date of student's or staff member's last exposure to person testing positive for COVID-19. *
MM
/
DD
/
YYYY
Is the COVID positive person living in the same household? (If "Yes," Explain whether they are being isolated from your child or not; or from yourself, if you are a staff member) *
Does your child (Staff Member: or you) 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 (Staff Member: or yourself) 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 or staff member 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 or Staff Member's Home Street Address *
Child's or Staff Member's Home City Address *
Child's or Staff Member's Home State Address *
Child's or Staff Member's Home ZIP Code *
Child's or Staff Member's Birth Date *
MM
/
DD
/
YYYY
Best Contact Phone Number (and name of the person at this number) *
Best Contact Email Address (and name of the person at this address) *
What was the last day this student or Staff Member was in school? *
MM
/
DD
/
YYYY
Has your child (or Staff Member) been fully vaccinated for COVID 19? (A person is fully vaccinated if: children 5-17= 2 weeks after final dose in primary series; Adults 18 and older= 2 weeks after final dose in primary series; boosters are recommended but not required at this time.)
Clear selection
Any other information you would like to share that might help us. (i.e. If your child recently had COVID 19, they would more than likely be immune for 90-days) If you have no information to share please type "N/A") *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Queen of Angels School. Report Abuse
Google Forms