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JLC Covid-19 Notification Form - Student
For all students reporting covid related absence
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* Indicates required question
Email
*
Your email
Full name of student
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Postcode
*
Your answer
Contact telephone number
*
Your answer
How do you normally get into college
*
Walk/Cycle
Use of own car
Parents/family member drops me off/collects
College provided transport - if this is the case please provide the route number at the end of this form.
Please select the date that you last came into college (that you actually came in, not attended virtually)
*
MM
/
DD
/
YYYY
Are you reporting yourself as self-isolating or ill
*
Self isolating due to a member of my household/support bubble displaying symtoms
Self isolating for myself (no symptoms)
Ill/ Self isolating because I have symptoms
Self isolating due to a fellow student having symptoms/having tested positive
Reason for absence
*
Your answer
Do you have any of these symptoms?
*
Persistent cough
A temperature or feeling hot
Loss or change to your sense of taste/smell
None of the above
Required
Please list any other symptoms
*
Your answer
When did your symptoms start?
MM
/
DD
/
YYYY
Have you contacted your GP/NHS/111?
*
Yes
No
Have you had a test for Covid-19?
*
Yes
No
I am waiting for one
I have not been able to get one
What date did you have the test/attempt to book the test?
MM
/
DD
/
YYYY
If you have been tested, what was the result?
Positive
Negative
Awaiting result
Other:
Clear selection
Have any other household members/support bubble members got symptoms or been tested?
*
Yes
No
Are there any other students who you have been in contact with (friendship groups, classmates) who you believe may be at risk? Please provide their names.
*
Your answer
Is there any other information you think we should know?
Your answer
Do you have any LSA’s in your lessons with you please answer Yes or No and if the answer is Yes give their name
*
Your answer
Send me a copy of my responses.
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