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Brennan High School COVID Data Entry Form
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* Indicates required question
Student ID without the "S"
*
Your answer
Student Last Name, First Name
*
Your answer
Student Birth Date
*
MM
/
DD
/
YYYY
Grade Level
*
Choose
9
10
11
12
Date of Notification
*
MM
/
DD
/
YYYY
COVID STATUS
*
Choose
Tested Positive for COVID
COVID Symptoms
Exposed to COVID
Parent Email to provide link for Remote Conferencing
Your answer
Student Email to provide link for Remote Conferencing
Your answer
Date of first student absence related to COVID (Type NA if student has not missed school yet)
MM
/
DD
/
YYYY
Is your student involved in Extra Curricular Activities? If so please list, if not please type NA.
Your answer
Your Name & Relationship to Student: Last Name, First Name, Relationship (mother, father, grandparent, guardian, etc.)
Your answer
Phone Number
Your answer
Has your student had a known exposure to COVID 19 in the last 2-weeks? Type Yes or No. If Yes, also type in the date of last exposure.
Your answer
What type exposure was your student exposed to?
Community
School
Home
Unknown
NA
Clear selection
Symptoms (Please type NA if student is not symptomatic)
Your answer
Start Date of Symptoms (Please type NA if student does not have symptoms)
Your answer
Last Date on Campus or at NISD Event
MM
/
DD
/
YYYY
Vaccination Status
Vaccinated plus booster
Vaccinated without booster
One Vaccination shot awaiting the second shot
Not Vaccinated
Clear selection
COVID Test Date (Type NA if student has not been tested)
Your answer
COVID Test Results
Positive, my student has COVID-19
Negative, my student does not have COVID-19
Not Tested
Clear selection
Type of COVID Test
Home Rapid
Doctor Rapid
PCR
NA
Clear selection
I know and understand that I need to email all doctor's notes and medical documentation for this case to Brennan's Nurse, Nurse Causey at
amy.causey@nisd.net
& Attendance Secretary, Taylor at
laura-a.taylor@nisd.net
yes
no
Clear selection
Submit
Clear form
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