Heath Springs Elementary - COVID 19 Information Form
EMPLOYEES SHOULD USE THIER DISTRICT EMAIL ACCOUNT.  If a staff member, employee, or student has tested positive for COVID-19, reports symptoms of COVID-19 or reports exposure to a person contagious with COVID-19, the administrator or their designee should collect as many details as possible.  EMPLOYEES SHOULD USE THEIR DISTRICT EMAIL ACCOUNT. This form should be filled out from the student or employee's perspective.
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Email *
Please indicate role (student or employee): *
Work or school location (check all that apply): *
Required
Student or Employee's First Name *
Student or Employee's Name *
Student or Employee's of Birth (for DHEC Reporting) *
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Phone Number *
Mailing Address *
The employee/student has......(Check the all that apply) *
Required
List the date of your 2nd COVID-19 VACCINE
LEAVE BLANK IF YOU HAVE NOT RECEIVED YOUR 2ND VACCINATION
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For those who have travel outside the U.S., What was the date of your return to the U.S.?  (leave blank if not traveled outside the U.S.)
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List of Symptoms for the employee/student: *
Check all that apply
Required
Date of Employee/Student's First Symptom of COVID
 Leave blank if no symptoms.
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Date of Employee/Student's most recent physical presence in a district facility, school or office, including all locations. *
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Date of possible exposure (leave blank if unknown)
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Date of COVID-19/Coronavirus Test for the employee or student listed above(leave blank if no test)
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If the employee or student was tested, have you received the results? *
Date of Employee/Student’s physical presence in a district facility, school or office including all locations for 48 hours prior to the sample collection for the positive COVID-19 test.
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Please list all individuals or groups the student or employee been in any contact with since the exposure or 48 hours prior to the positive test or first symptom. *
Please list all individuals or groups (include LCSD students or employees) who would be considered a close contact since the exposure or 48 hours prior to the positive test or first symptom.   *
Close contacts are defined as two individuals less than 6 feet apart for 15-minutes or more, with or without a face covering/mask.
Please state any other relevant details and actions taken, including when a family member began symptoms or took a COVID Test. *
List all LCSD employees and/or students that also live in your home. Include their school. *
A copy of your responses will be emailed to the address you provided.
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