N.B.H.S. COVID-19 Self-Reporting Form

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Only complete this form IF, you are experiencing symptoms or tested positive for COVID-19.
To ensure that NBHS can provide support and resources to faculty and staff who have been exposed to or tested positive for COVID-19, the School is requesting that individuals (or a designee) complete the form below. This information will also assist NBHS and public health officials with monitoring the incidence of cases occurring in our community.

Please Note: NBHS is committed to ensuring that your submission remains private and only will be utilized as a means to provide support and resources. Your submission is not a substitute for medical advice. If you are in medical distress, please call 911. If someone is diagnosed with a confirmed case, the Polk County Health Department to make sure those who have been exposed are contacted.

Full Name *

Home Phone Number *

Email Address *

Position at New Beginnings High School *

Last day at work *

YYYY

I have been experiencing COVID19 related symptoms as reflected in the addendum? *

Yes

If yes, please indicate the date you began experiencing these symptoms.

YYYY

Did you have knowledge of these related COVID19 symptoms prior to coming to work. *

Yes

Did you notify an administrator of these related COVID19 symptoms prior to coming to work. *

Yes

Have you reference the COVID19 Employee Handbook Addendum and Employee Handbook? *

Yes

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