Brashier Middle College Illness Reporting Form

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Please complete this form if showing signs of illness particularly COVID symptoms. Please also report a positive COVID test or if you have been identified as a close contact to a COVID positive individual. This form should be completed by the student and/or parent/guardian of the student.

The school will contact you to determine the best plan of action.

Student's Last Name *

Student's First Name *

Parent/Guardian's Last Name *

Parent/Guardian's First Name *

Parent/Guardian's Phone Number *

Parent/Guardian's Email Address *

Have you been informed you were a close contact to a COVID positive individual? *

Yes

If identified as a close contact, when was the last day you were with the COVID positive individual?

YYYY

Have you taken a COVID Test? *

Yes, it was positive.

Yes, it was negative.

Yes, I am waiting on the results.

If tested, what was the date?

YYYY

Do you have one or more of the following symptoms (check all that apply). If without symptoms, please select N/A. *

N/A

shortness of breath or difficulty breathing

loss of taste

loss of smell

new or worsening cough

fever (oral temperature defined as 100.4 or higher)

chills

fatigue

muscle or body aches

headache

sore throat

congestion or runny nose

nausea or vomiting

diarrhea

Required

What date did you begin showing symptoms?

YYYY

What time did you begin showing symptoms?

Time

Have you been to school or to a school related event since you began showing symptoms?

Yes

Clear selection

Do you participate in extracurricular activities at another school? (i.e. football at Hillcrest, cheer at Woodmont, etc.) Please answer yes or no. If yes, please indicate what activity and where.

Have you recently traveled? *

Yes

Submit

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