K-Grade 2 Student Report of Exposure, Symptoms, and/or COVID-19 Diagnosis
The information you provide on this form is considered to be confidential and private. It is important to understand that Public Health and/or Minnesota Department of Health will be notified of this information as is required.

Please complete this form as accurately as you are able for one or more of the following circumstances.
[1] Suspected or Confirmed Exposure to COVID-19;
[2] COVID-19 Symptoms; and/or
[3] COVID-19 Positive Diagnosis.

The form MUST BE COMPLETED with 24 hours of exposure, symptoms, and/or positive diagnosis unless there is a medical emergency preventing you from doing so.

You MUST complete a separate form for each child.

Thank you.
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Email *
Legal Last Name of Student *
Legal First Name of Student *
Last and First Name of Parent *
Parent Phone Number (where you can be reached at anytime) *
Date of Birth of this Student (MM-DD-YYYY) *
MM
/
DD
/
YYYY
Current Grade Level for this Student *
Please provide the names and grade levels of any siblings or children living in the same home of this Student. *
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