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COVID-19 Case Collection Form
Please complete this form to share information regarding a confirmed case, any known household contact, and any known non-household contacts. Please complete one form for EACH individual affected and/or incident.
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* Indicates required question
Email Address
*
Your answer
Please enter your first and last name
*
Your answer
Is this a student or staff case?
*
Student
Staff
Please enter the first and last name of the student or staff member affected.
*
Your answer
Please select the building(s) this student or staff member attends.
*
Paola High School
Paola Middle School
Sunflower Elementary
Cottonwood Elementary
Paola Adult Education Center
Other
Required
What date was this person tested? (please leave blank if not tested)
MM
/
DD
/
YYYY
What were the test results? (Please leave blank if not tested)
positive
negative
presumptive positive
Clear selection
What date did symptoms begin? (leave blank if not having symptoms)
MM
/
DD
/
YYYY
What was the last date of exposure to the positive case? (leave blank if you are the positive case)
MM
/
DD
/
YYYY
What category does this student or staff member fall under?
*
Confirmed positive case
Close Contact of a positive case
Household contact of a positive case
Relationship or name of close contact involved in this case (optional)
Your answer
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